HomeMy WebLinkAboutMiscellaneous - 121 FOREST STREET 4/30/2018 (2) 121 FOREST STREET
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Town of North Andover
HEALTH DEPARTMENT
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CHECK#: DA E:
LOCATION, f �I
H/O NAME: borahv
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ TrashlSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $ `A I
Title 5 Report k $
❑ Other. (Indicate) $
L�
Health Agent Initials f
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts I
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /
121 Forest Street V/
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
"I� Company Name
VQ
111 Argilla Road
Company Address
Andover MA 01810
City/Town State ZII
978-475-4786 SI15 R _�EIVE r
Telephone Number License Number
JUL 08 2014
I N OF NORTH AN,.B. Certification HEALTH IDl pgRTMEM
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
❑ Needs Further Evaluation by the Local Approving Authority
6/27/2014
Inspe or Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I ' I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown 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
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown 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?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins•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
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. CityrFown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 6
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Yes
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17
K\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Pumped 2000, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined?
Measured tank
Reason for pumping: Inspect tank, tees& baffle
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 UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
U
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
28 years old, 9/4/1986, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4"Cast iron through wall, 3" PVC in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 4'
Sludge depth:
8"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
(I UVTitle 5 Official Inspection Form
-,. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every 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
25"
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
7"
How were dimensions determined?
Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee clogged, clean same. Inlet baffle ok. Outlet tee ok. Depth of liquid at
outlet invert. No evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
..''r 121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level &distribution equal. No evidence of leakage. Evidence of carryover, pumped d-box
to clean.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-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
< 121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3 trenches 60'
long
❑ 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.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
vr121 Forest Street
Property Address
David Kazmer
Owner Owners Name
information is
required for North Andover MA 01845 6/27/2014
every page. Citylrown 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every page. Cityrrown 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: >4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 9/4/1986
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As built plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan
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
JD rm
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 121 Forest Street
Property Address
David Kazmer
Owner Owner's Name
information is
required for North Andover MA 01845 6/27/2014
every 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
• Summary Record Card generated on 6/12/2014 1:11:17 PM by Maureen McAuley Page 1
Town of North Andover
Tax Map # 210-106.A-0173-0000.0
Parcel Id 17317
121 FOREST STREET
KAZMER, DAVID
KAZMER, NANCY
121 FOREST STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1 Acres
FY 2015
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
KAZMER,DAVID Payor
KAZMER, NANCY
121 FOREST STREET
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17613.0-121 FOREST STREET Last Billing Date 4/2/2014
3170284 03 Cycle 03 Active
UB Services Maint.
UB Meter Maintenance
Account No.3170284
Serial No Status Location Brand Type Size YTD Cons
34429291 a Active ERT F.L. b Badger w Water 0.63 0.63 684
Date Reading Code Consumption Posted Date Variance
6/11/2014 725 aActual 23 14%
3/11/2014 702 a Actual 20 4/11/2014 10%
12/10/2013 682 a Actual 18 1/17/2014 -68%
9/11/2013 664 aActual 58 10/15/2013 147%
6/11/2013 606 a Actual 23 7/24/2013 31%
3/13/2013 583 a Actual 18 4/22/2013 9%
12/11/2012 565 aActual 16 1/9/2013 -58%
9/13/2012 549 a Actual 40 10/15/2012 94%
6/12/2012 509 a Actual 20 7/16/2012 -3%
3/14/2012 489 a Actual 22 4/14/2012 -4%
12/9/2011 467 aActual 21 1/17/2012 -63%
9/12/2011 446 a Actual 63 10/13/2011 74%
6/7/2011 383 a Actual 34 7/20/2011 87%
3/8/2011 349 a Actual 18 4/13/2011 -39%
12/8/2010 331 aActual 29 1/12/2011 -56%
9/10/2010 302 a Actual 70 10/15/2010 137%
6/7/2010 232 a Actual 28 7/15/2010 49%
3/9/2010 204 a Actual 19 4/14/2010 -6%
12/8/2009 185 aActual 21 1/12/2010 8%
9/4/2009 164 a Actual 18 10/15/2009 19%
6/8/2009 146 a Actual 15 7/20/2009 -19%
3/13/2009 131 a Actual 20 4/29/2009 1%
12/9/2008 111 a Actual 19 1/20/2009 -40%
9/10/2008 92 a Actual 34 10/10/2008 -25%
6/5/2008 58 a Actual 40 7/16/2008 138%
3/11/2008 18 aActual 18 4/11/2008 0%
12/10/2007 0 c Correction 0 1/22/2008 0%
11/29/2007 0 n New Meter 0 1/22/2008 0%
11/29/2007 3038 r Replacement 56 1/22/2008 2%
9/5/2007 2982 a Actual 51 10/12/2007 207%
6/18/2007 2931 m Manual estimate 20 7/20/2007 31%
3/15/2007 2911 m Manual estimate 15 4/16/2007 -9%
• Commonwealth of Massachusetts
City/Town of
q.
System Pumping Record
Form 4
DEP has provided this form for us&by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this foram,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left i ht front of hous Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
P �vl
City/Town State
Trp Code
2. System Owner.
Name'
Address(if different from location)
City/Town state
Telephone Number
B. Pumping Record
CK1. Date of Pumping �epticTank
tity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [g-MV-� If,yes, was it cleaned? ❑ Yes ❑ No
5.. Condition of tem:
6. System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L ere contents were disposed:
CSL S'. Lowell Waste Water
Signitufe Haul
Data
t5fbrm4.doc•06/03 System Pumping Record•Page 1 of 1
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- ;COMMONWEALTH OF MASSACHUSETTS
fX41K,; �� h ?, ?�i 4 ?�Y i�QF J,!QF )ENVIRONMENTAL AFFAIRS
=DEPARTMENT OF-ENVIRONMENTAL PROTECTION
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" OFk' CL INSPEC' 'IO T FO iM--NC�T, OR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE" ISPOSAL SYSTEM FORM
m~ PART A
a CERTIFICATION
rtr�r' F � x -�qdt�„/G1�..riS �i.?f��7,J�."111 S;F sal i7.i..,4J�i A`.: tl. �4)`f lei•.J�it��.;7: .., ..
t {
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,,".'Address! .
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f ty 3
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`" ' ��tryr��'��iOwnerls Name;
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" 1 F �•�'`�'�`' '#4Y�1't$'a4,•�irese�"_^" ,
,' ��F J rY 1.'•r<..�e°tC t } r i ......_... —...., ..,. .tw,..,,.,., ._ ... .
[pms or'lasp ctor:(please print) S
.�i.fah V'I
St,CQmpapy N me{'SO 5 C ►i**//•i�i�
d�'gQ,� a 1 f .� 1 .1�•:?� i:'
iill tits,c ,�•. .,� (0 '':d!. i,:fT'SIJ 31I/� :.
i� : t,T lephoAe Nuwber.47 �� C—„l L100
� ��i'��;;��'�`yf�t aV.r.. •' ,.a�.' � hf�Z. - i �r3i.r.Jili32-�rtlS14k •.. .
R CATI0N STATEMENT.
certify`xhat 1.have personally inspected the sewage
below g disposal system at this address and that the information reported
yet f. >�letG, t4fi=.Qf ,uts1?eGt'on.-The inspection was performed based on my
e;t rten
, ' :1'rplgcttan attd mtetce,pf on site sewage disposal systems.I am a DEP
r i approved sy$te41 inspector pWrS ant iso ion la 4#R,Qf Title S(310 CMR 15.000). The system:
t %} 's'y iJ i"'pn. r ,. .. ♦di41i'r n4.. a Y Sas. 1 ..
t
s� tSt�C#S.0 f kt tt "7..1�3SaFf�+
Passes
Conditionally Passes
Feeds Further Evaluation by the Local Approving Authority
^*d3 h /fitx
d,
f19e�QlrN F1r'�iSt1 folp
Date:
i
be S t ins .
{ Y �yY { Y . 1?4xWr'sbaU sub t a copy this ins cttou report to the Approving Authority(Board of Health or
1�yithitt,30 days of completing this iuspectioa, the system is a shared system or has a design flogi of 10,000
gpd Or.greater,the inspecWr and the system ownershall�submit the report to the appropriate regional ofl ice of the
should be
sgnt W the system owner and copies sent to the buyer,if applicable,and the;�approving
"',.,•r+;' xY� antltortty. � 'a.:« t ,r,
Tc-4V
OF
(?��c�iq h�9au �Y 4U u 4,2it�1�#03 bvb asp L r st G�,4 for)
x r kr a aCra- .qct r p• r - — -'
;* `� t1¢' ann,,s,�+S.ry�'°vF�•'.H y w w ; f :, e 7Jy�+�k�(y,�1 it: APR I
w h;*tt#'1'lus repo t only describes eoaditions at the time of inspection and under the conditions-of-use-at-that)
.tittte.'Tbis I�spoetton does not address bpW.the system will perform in the future under the same or different
orf r��, ���;3�s►nditiwns of use. --
L,�c�3,1w^r� �i.'� Y"�K}5�i(A X 'n • .
fM1 a x'f y ySKWspat�om Form. 6/15/2000 page 1.,
u r u
3�` �..',1
3 rtf � tX R n�tr .� t a `�, S it�' ;I 5{ tr]',, c
$' t'a>•{.'ss�p t jy t'Sx p ''� tr'J'rxt� ,tt' �' �ti !r ! +
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!i e i '' `�tw�}1�•a { p v fait .,�,�•r}
A+cW0l +i+11 Lin
C�"aINSPECTION FORM 11TOT'FOR VOLUNTARY ASSESSMENTS
�•�
f4
4',
'�STiTBSI.ACE SEWAGE DISPO S
SAL YSTEM INSPECTION FORM
PART A
zl CERTIFICATION(continued)
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���'T��''i��.� �l�t• ' IS`° V,f�x3rH"; eC F d :' I : - •M k.►+,el.1.��L {�.
{,te 1 .�{N.tt ^�r� 411;r,'4 yi�Fear�r r�.•Y.'s;t v� Y
Fyf G !xlyr" ktCbak A�B,C;D orctnplete Aq of Section D 1
Mat n qwa-
{{
{�'Ry*��, x 1 �{ y� '1�M%is°�4'Yt!{"'e ,r •, I
�. 9}•'� AFCl tt �r�' Mp"Aot fowld aaY lAolmatt0n W ` l s�'�e4`" e��'�t
{ t
I
htch indicates that an of the failure criteria MR
t ' 'x ",f ISQ 9F,ut 30 CMR 15,304 exist,An Y teria described in 310 C
x'fir , y failure criteria not evaluated am indicated below.
-
4
j , rr, f r 3'S r ,� +�y55•,5 s c•r'a�
1 'ri i� I '
I6F�`}, tf:t{s41;i-... t F r
• �'�'7'�'��t'! i�,'�tT?41 Utz f%�R!�I art i` a t r �
W L�1 ' �1r i 'tr t r y,X�r 1,j�•+t'rYn� _. .. .. ��. S
7 Yf „r.
#.tF"'dpt'
d ii.1aA/�he3�lft�f�reMy��}GIS
Ponce as described iu tlie'"Conditional Pass section need to be replaced or
km,upon completion of the replac 011t or repair,as approved by the Board of Health,will pass,
Y
f
'y.-iF rr r�. �d,#t�'�,;'P��hy��g'A�lt[Y'�'S+�GNtn+i:�. {� �a•tk qn�e SF .,t ' �. 't tf t�r l.zi ... . .. _,;.
ao cll�tcrmuap� ,N,ND)u►the '` for the following state >t
1 'r
i, res�latn,Yf 1w[t 7 ----* ments.If"not determined"please ,r <
! K �•- -. septifiank is Metal ears old or �j
tai and over 20 Y the°septic tank(whether metal or not)is structurally
sitbstantiai iti'ilto>i ,
Qr exfiltratiori'or y
att� ' tank 'ure is' n S
X31 mimine t. ystem will pass inspection if the
y r 6 tatllc is mplaced With'a ca 1 '.
mP Ym8�P }tank as approved by the Board of Health.
� �{,� fz A septic tank Will Pass inspection if it
tank igss thea 20Y SQ�'not leaking and if a Certificate of Compliance
Yds vatlable.
-
!g t ti, 'i r��I�{`�i:'�f��lf'� 4bY4s{f��`,'k;#Il.ji��, aSr!� �i�l Y)Qa;L^)t ; I Y •
.p' V.- �!�,•�y L�'44Ut trite Vi„ � P, r �t llri } I
•"
�9w�,� � ;5
r++s..l., Qe ~"�'"'"+!�"Qr break opt QR hi
"` f gh water level in the distribution box due to broken or
OR`' Fx� ��r pS � `■ + At'�eM�distrtl�utwn box.System will pass inspection if ith `:!
i�kt4��kt.,+•,� FY'7ty f 'gR � I, .h • I l
III• t. - t 1 ,i ^' ; /___•
j#Il�'(SY$�'4paa r lFi 4 .
may}=SY�ij I' �FI4 qr ;,kef'aJ,+'a}1[y `""lrFF ry�,7*i1<wr+ �.yig+'` ��r%r •�p}• Q�M�trtrtwWQo1Yy0sy{��rJ; ,?y1
R �.'�d�'4� � � � trvb�(���$9A�M1f�LMu"�!°'M.qy.�}.i�,f�7 �r�'t �I1 •7'wMM��`a4r.+�11MRM Q�•�•pM.MtrY t alt}1 R 1 � :
� �t Kir.., 1�����1�aFyx�i irf�l���t�li 3�Hi t1�?['� FN y�5�f l!I I'{?i�r i�` I•.
t•A4 4d R
���r 4{°tk > � ) ,,r a« tt t �, , ` `I„ '..•.
t'R: t?
"q,_4W pumping .more than,4 times ayear,11110 t0 broken opipe(s).
r obstructed i s The s
�F r �(1yi vel,4fP Pe( )• tem will
a
7f � Ct�N�t�}' qty }y��[� 'Q *np �-f •�') �r
t sir s kfi�?t '{f tl�r r tih a fir 7 K obs»w4Y{n is remov�pd ,'�' i '`' �i•. 'I
` ';s"T3''Y,i•`+' _ 4,��,���'.�'����jlfF�-�i'� I'Qr,�I��iJ r�'}��J���HxS� t �,��'t 1�7'i',�s S��'H tip ., .�:
t; - a t $' '����aF�ra�s��N r I �`*•b y t �,.;;
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y,•�V���'}ix ".int '44 tif'!I tt ! -0 1'e f ..r !{.,'� r�+r s ti,t".�y�
.G �4,�'ryrF.dt•!F>f YtYa f ! 1 e c.'t �i�.a 5 ,w y4. ! { i"�f�'.
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r� -1�NOT,'FOR VOLUNTARY'ASSESSMENTS ;
SYSTEMINSPECON FORMDISPOS v
�z5t,,i'1t,+,�r}.rr�tt si i 5 rt. t( -i• u c 'A.
PA►Rie�.'A '
CERTIFICATION �.
1N• •�
11 041 YA
EI n5zZypfC qsy `,Oro
r z cf♦d��
• y1J �t 5 k^ ktS} tl. Ii4 4 .^+V• i - t ( 1 }; - r A
" �' � M1 ' eYAlipti1 Raequire,d.by tbe, of ;J '
rZjl board. ltll•.
490 ,u: r
w)u�h, '�Gvaluatian by the Board of Health in order to determine
t *, ► Prolia public health,safety or the,environment. if the system
.'.
re: xy "'�}'�}Vi,.ff'f�l�hrT�,�•� er i i :r.;,t r � ,i t _ ..:. .. r
oda 2ytA }rt,' r ii%y�.!!!r„fi ^A # o St HeYlthd�te p p.A�r�nce with 310 CMR 1&303(l)(b)that the `�}4
protect public health,safety and the environment:
pOQI or privy is within SO feet of
a bordefittg vegetated wetland or a salt marsh
i 4r 5 } rf 3rh +i {�'}�.Fl 1�ys St f17: a .11s} ! ala-it�psP I1.J. rtit
0i 'I�r
l
4 A-7,Y,
t +' �:. '� F ��'� '�5'.5 tj'n �i r” t r r i' - i �` 1 r i r,��•
�4�a
I fit i., ,� ��� h 4h r>;� .(.�(�10( ;.Ix�'fi.t++� 'F`�'7�7i�!{{i.#_7"1,���"lc l�f " '•'li'd
ins , ,..SYi3tWat; r�iU flit uAle,sa we
In Boad of,Health(eu ,Public Water Supplier,
�? s� , Ijtq�Wonlog mor t if any)determines that the
X:
?fit tar's " iE}t y',t r aprotqU0 pW4ilC'be,alth,safety and environment:
�'id s� xy'fi,S{+�' f'r7. tj tij xrtY i, iu�•-r5 c.:; , �5 Nrl.• 5 r -r+ p.
J���7+1�f1�{ tl't >" ,w'"M1°r�, " §.:. >• :rtr It���'P+�tll�1` -�;�� ii:' r.
/� 4"��rl�, �,..,_,; p s�yYs ►ba��; ppC tk Bad so><t
abMPdou systeam(SAS)and the SAS is within 100 feet of a
"W NPA1Y
:or trtburyut�acG wate,r�u 1
�� 'hr: a l -t'�f p �31 + ii hr� liiNr t r .. - �•
,��Qt, r.�� yr or,; �7`��7, �'�`• I ii l9 �..'d# -�1 S�f'•Y, F-i�5�3, - tSt :'3E�ar'.'i� � •
SAS t�Ad
SAS is within a Zone 1 ofa
public water supply.
ttl 4{; i�.ti d4(r "1�•�PJ t
�.F1 !'4
tl •'1.' t�*�'}"i? 41 aqd AASapd,� is within SO feet of a private water supply well.
+ r Ye*r h f t�+,p�tn Q. :s}�/�.}t�,�,°i�`e.w.�YQ..�� " r j .
N �1t 5 �l,� I. �^�i1R.: Y ��ltM w!!GPM%%AkaM..WLA.A1�tld:t Y.
wOli* Otis:
�S:is less than 100 feet but SO feet or
Yi �rt� µpp x ltl dGAanmuladistance more from a
+�`r t�(��"�"P r 'S�,i'r kha±X" JAt '•, ` ;' � .' 'i '1 1
he won Wit'"Ysi1% at a DEP certified laboratory,for
� 3-� ��� ,z�.atal;vplatilacgM rY, coliform
z is free from pollution from that facility and
F $a4 t#Ad Attrate ill en: Well oro 11
t "N"nY �$ is equal to or less than S
A c�ppy.gf thG eual is PPm,provided that no other
±:,, AWOC`attached t0 this form, j
t-° � r i � flt �I•r�tl����`}t J ,S h't„ j�'�r { r s ii r, C�1�� .4y1blU�, ( ,5 5 rl� . � .,. .;.
r r ��� e •r � t .l1 a r 1`r y�
jp
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it
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411k i idl�la rr tk{ tbN apt;�wri l7 Pit r41,1:ltYt !✓r( �'! ,, .�,
1 � �v � v P".F" � ".'1�SA��t�f,�}� !E'r �y Y��� `d 9-''i�a w � y r ` .. t�✓.''„�...
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N 'ETION�FORM �NOS FOR VOLUNTARY ASSESSMENTS �
'� >Sy ate 1 xta
SIMSMACE SWAGE DISPOSAL;`SYSTEM INSPECTION FORM ,
I� fY�;`�z f •S. F+I `S}y 4 Y ilioT A
��CATI(�� /�
A i w 7 Ti T t r a e i , f ”
(aN(conUnued) 7.
!fit
#t.y 'rN 'S 83•rft+'��,��a,,�.}��+{��.fit 'F ri, s Y��t it.''• i ..,y11
���l+bR1i► 1 '! � � r i' t it'�'i
R
C, . r 'Iva
S, I ;
,j � 02t�a.�y
Lail
r aPA�4k to aU ryatems a_
fik+5 4,t � ►�„#.or 1�Aonr to CaG)�pftt1G fO110w1n I u`
, g for"lnspectiora.
�}r��.gT�*{Iypap�'�,�..*t�, .�'r•:,
i►Ir..a°"'.'.ww:YMMi4ty+ora
Yom►COMPOM t due to overloaded or clogged SAS or cesspool
Ponding:of effluent to the sorfact of Idle ground or surface waters due to an overloaded or
Clogged SAS or cesspool
,
4 '” r gz :,1u1 level the distrtb ton box aboY4 putiet Invert due to an overload
cesspoo ,. �; 0 ed or clogged S
1 e .�'t�f+'T'1 ttN 1? 11.<"f'r, .r.1.:�n;�.#gi;),.y, , AS Or
��r+it�•+}•y.#'�s�+, t s .yr ft s�r `u a�:.V��'>��r
rK P ►M Cesspool 4less than I below invert or available volume is less than /day flow
' f � A P=PiDg more than 4 times in the last year OT due to clogged or obstructed
Of aloes P�,tltuped jted pipe(s).Number
'
' ►pf the�►AS,,ceopool or privy is below,high ground
waterelevation.
Y Peron of cess 1
i 'G � perp an P�vYt�a 100{feet of n surface water supply or tributary to a surface '
r r ��AR "# . ►Y t J a 1 1 zW I'of a public weU.,� nessAoo �prtvyris�►iWia'a
YPortion,of a cesspool or Privy is Within 50 feet of a private water supply Y
�:< �Y r,e rT K+ t►y.porton-of a pop privy is.ICss P 1 well.
Q=Pool or than 1Q0 feet but greater than SO feet from a private water
1Y-well.with no acceptable water quality q ty analysis,[This system passes if the well water analysis,
PeNonnGd at a DEI'certified laboratory,for coliform bacteria and volatile organic compounds
let the.well is free from U
la tition filptn that facility and the presence of ammonia
' GA sad'
altratc nitrogen is equal to or leo than 5
ppm,provided that no other failure criteria
T+ � x ;sure gored.A eo Y Pf tbs"*;is must he Attached to this form.]
� ted TbG i�yatau4'fai,�1 I have,.
defined 49WOr more of the above failure criteria exist as
" ��' ''�q dGscrt'bed iu 310 CMR 15.303,thGteforG the s Y
r dote yst m fails.The system owner should contact the Board of
` z ,+xP$�'`"S rmine Wliat Will ben to;
�
"} ,3 ./ ,r# t g r!*� 4k�.nf necessary W GGnT4 the failure.
Y tF s� r t srft? I1�
X
!!��^ �{ �f�NA7�!'.•c4{.1,,�^�1��'�,3?afYRt!i����"SAMj��d�}��ll 4��jl�R�J��4}1�!.t,tf 4j:}� [ } ,u;: ..
# c � ��`��F�+?�t'�-,��,���`#i� s��jy`'rStl6`'1.�':il�{1' tS►�r,�'ri'��:,,lX3�riitjr{f ,,
, g r1 ;a,1.ri� �� r ayStemt, #We a l�,ty with a design now of 10,000 Bpd tomut
X5,000
� t �"yes"or"no"to each of the :, �
� followtng ,1'
to Ira sYstatns gun addtgoa to the pateria above)
•#jq`�t�M.�i,. 'fi%41p[�ti1'�'�$t;{7�+�8�j��//jj,'i�,�Q��[(i to x',A.��Q�r�r��•.;�D r, 4 � 1__'�,•c r � t,.,�
WOW-$4PP1Y
1 , T9 n R9 "W +�g ate&f #ug water supply
��5,� �� t� � r #+tr4i•[ r;v1:.:: t.;_.. i_, �'t t�r .� t __, ,. i 'li.#t<:�.
*Kawul a' o$e Astave aM(U*641 Wellhead Protection
s pabliC WatGt'supply weU t Area—IWPA)or a mappgd s '
r ' ..
r Yro i� ;"Yoa" aPy�oestiaa w Section ,the
ab YG the $Y$Wm is considered a significant threat,or answered ;s
1g system Tim pwW or operator of any large system considered a ;
or under Seo '�
upgrade the system in actor
should Contact a Y dance with 310 CMR
Y�4
PPP�te regional office of We Department.
"N" s
14 K {S'.5hrk�4 ; 5� .l4 i 4 1 i
p ��r.,y'{,Y+ �i"` r'rt''t'��,t-it•�i,�h{A��,r �i r}, xr!-t`rk - .
,
��.., 5 1 :� d'tl '44 .4 twS'; '.�
C k+ hr, �j�}Jst` q,,' a arfkSrj htvJ .' �,,E '*"4.°,,� .>• 9Rtr�'1r y1� v 9 y.
r�i�� SIR
"� "•$.r d rrf�, "; ,,n#'Yy'�Y+w3 t j ` 1`k '4(krFi
zEM
�*�'��(,�1c�.�r h.oti•ie'�q{ t�'4 t;�,�, E��'�'t.i 4f'"u .,( A,J fit. '- + fi =.5: 1. . t I S iY�, '1 �
w c /
�f l�su�t�i `�+',��.1•�y`rs�+f' A•�■ •�If��� r..:, :-'
.ori FORM NOTYOR VOLUNTARY ASSESSMENT
- ACES. W,t#GE DISPOSAL.SYSTEM INSPECTION FORM S
,N I
r' 4 P
7
sgj1{ V,CHucST
x � s L'tr`i ��m tg� A;f m,i„• J 1: �w� Tia _ ,.I" 2:
�;.
f , 1�+1 r.
, •• ,J i,l i���rf5 "�'`gY F}gr,}5��� rt�'�a�'ri�r S. 3 a y ,t , i � .l �_' _' T .• ;7y,�.J�•'��}l
t jA�`�✓✓�+"! r±.}t,�� lilh l�` t'#f to- ('kji e i. i t " �f f.) a� i10i;
yawm u�,,..
Check tf the followrC J r f D �,r
jSJ have been done You trust
indicate es"or"no"as to each of the following:
-
c
y IT l tI
�`% *�`� ��uRQ_WM pmvidod by tbC owner Occupant,or Board of Health
c
*.
ti,WR qty gf tbo system components Pwnped otu is the previous two weeks?
g
f �
f ; Y1t J �u tY�fC, i 4tnh'e s++y-st_Vw'.�r recex.vai fA,Q-r<,m. a1 Paws
s InWG per lno•us two
week period? Sr
'
�
irk�`� i y,•���4ir�"'t,����. ip
Qf been Wat�it' �
u►bod d to 04,system recently Or part of this inspection? 3
{' *s Afthe system caused
f �s bolt stens ob
�" " Y bpd wcaaained?(If they were not available note as N/
A, •v"�,
ra �1 � '"k WAS the�al�y or. w t�
r k r d elling_ petted fob`SW}S of sewage back.u
C ci F`' E)Rt<F J.!�. lt" '3�4.r,44 2 E' j , ` `•' r.- "'77
N j� 9,�ig1 ,1 to:x - 4 t' �1+'I�t�A�M stt�i. , r F,4..
r fikejt�,
-.,Ato
forslgns of break ut f
},
u 'F t�l�i�r�d�iyrf +ix•'�itr� ` f�� �� i''r� ' �'` �- r '' rl {�tf.:7 ,,. rf f
30131e1:113,oxcludwQ�E 4C ocated on site fit• a$ � ¢. f 4 + , ?`,t J{'fh �/Rf�.�IrAM�� '
lyMl Yr 'ry.7.t�12 of i
"h `„� r' <.°�^.-. "'Were the 'ttc tank manholes uncovered,Q j
�� 7Q los Qt t+pes,Material of �the interior of the tank inspected for the condition:.,!-,: „a�
gAnst uction,dime#110,1 s,depth of liquid,depth of sludge and depth of scum
•S
��f'��k/ •�i���41"•F f II��'�{L l..,. •. :.. A- :.` •e.'. _�. y -t P ?
, py" 44.cilityi owner(and Occupants if di$ert
. t ff�u 4 t 4tt o'' . + ,ryrfacersevva Qi a fonowner
f )Provided with
information
systems on the roper
1w"r,dy%
�• ' .}(ybs '6y� t S} }:J'a Y t;5 6. ^^!•^J•++a*^?r*ta�I
r•g>,« ...'
,a
}5.
t. x .Wa3{�e� {ts �x
YV�gNi k� t x r ill i �'f Jf(J�t Mi���tFl 11rT t
` a' '�J��� j > ud locatlOa Qf the Sall Absorpt n Sys k'
Ivy, NY , + �► tent(S..lIS)an the site has been determined based on:
, Ar 5 5 a
9W..FA,c ainp �a p4 ltt,die Bmd;of Health.
M tie field(if auy of tie fault A
)� R Meted to Part C is at issue approximatio Of .
i1Q�alp t 1S 30 3 m distance
�yttIrl !.� y "�� _M4 y, UV'P•,I�C;�^t,.s} }� .1w,'S7'4'tf r r,�� = Ir t I •i •tttlt A � t,� 'rI :
tk,}k {Lr T9'It
�a va, i6 a # au fr.ltr+fr�,,j'b ti�J,?� s � f t 4 r •.a�'
� `� gra 'brnla A:;i �` 1!� t-�. t of lr e�t, '' '• i' l t 1 w?•..
>• ,, fir, MA iTA.,y Y'jr �},tr } ;:. .t, I• r T t ' - ;e'w`;�
•bt++
' F3 I. [ ,�q. 6��,f`,= , ,, +nry�+w!. r'tr-" ."'h.�,Pd..•T'S„'^,: - .., .... .. i' t •
i Y s •l�f ff °'{{j�ai 411�sief�X d:4t F t5{ r , t Y�(r),j�-.� � �'� oa(� / •d:T'�..i
�rir,`�; �� .' kryStS; x.Frj•v RtM yj h J7 '::S �t r. " �u jEj {.��7�,��}tyU�tJ 1�jY•��Jllf 7,+•" r
�r� f a �.f f}SFTaY�,�. Y(t l i, Y1e'n'";e'{"'1 <1 R'b�•+"*`"T,..1 .4 .l'd4:I
nr�l��'f'W 31•Y f� 3 }< jl r ' p !l Y II f 1t�t�.�j 'ta 5 f {�
G'I.R pl.;r" ")
��� Y�'r�t�a•�-�„t� r S � 3 f a J "' t f l t d'!v i
f: a `. �1.�>2T}✓{,+t T1s�''ti.F^1'1'��l s 1 4'4 t l.)2 �d..V't 5`' y r N < ,,1� `.`�,<.t
�. •�; at l{��',.^a�� jnl f pit x rt iF o ,, a 1 r ¢i!
'� . ,f t t r 1 ''i,���tt�l;.��.µ� �2e.i ;iii Ain'' sPt} � •, ,r alpar;'„`� , ,,,(} , ! lk.:l
ot,
tifz f£t,F"'4`" 'p if,r'd '�41'Al to*' ig '1Tpr•a'��," a° r.. k'� q✓�.,yr.,d -
�Y A t�,kiey a q7 ''"+,� B itt Y .tt'+ T T{?� q•7�P e y" I
MSpEcnoN-
>fi! t''An�s •i}§r1�si�. 4"�1, � +rq�;��.. t ,.se { � >' r•1t rt.` C r 'vi rF' -x 9,,
FORM ?NQuF 4R VOLUNTARY ASSESSMENTS
SWACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART��wa•
I C
SYSTEM INFORMATION
1Ynfx, ,Hj,2 r•�n RMATION r
° J
` r
rjf�try k°t , FLOW CONDITIONS
V.
, F,iN'hIAI'
lWiabacf ).•a t 1,s :Number am
of ` .
Frl2 .`55ty �,, a�.
Nflow' d'on 31.0 15.203(for example x#of bedrooms): l/a I
--1-__
g> °(Yes.At t10) y s '
03to (y+es or no).' ej '� if e� pection aired
r,Yyyyy ��••I,,e uulry ymm_.i�+Spe�tod yes Or DO1' �s:�.,c'17. tC ups required]
..I� ,):
,g�� � f „+71 'Jr!'� tr:°ctsf:1YQ•Y�X,�pP Lut�i}G.�, �'` ;",
`} k �N tax spa pgs,if vatlabla(last 2 years usago(Bpd)).•Z*t A�5 ./„o '
.
} �jC/�� I r•
31
RY
UST$L�L / r rt /I r
�}7y 1. 1 #1A ►]'(�1 }��tyA/aeu31/r0p CMR 3�)};� Awk
tt�I��T,r; P`4+!� " $,.,}'}f�(��„"*�;'!�71��'{\�Y�Aa=�X�ii1 fMNf�)�>) .•shr ��^
.�, ?i?�RS"'n! 1�V w'Ar nKte xt•: I�'t{°.
r7 �
R�u $6 tho:�1t10W S n(yes or no): ,•.,
-77
Cf
�.�I �1. Yt�F f�'1.,�+ `'MIt�' ..RIT�..I,. R t r t 1 i 4•r.
!li *hR4f
FIT a: I �d
rl.1r°7' }"'{'f �t� f r -tr°,i•,
�� ,it cr,�s, 4^Isat9at'i..;r:�l�g?1��'�a�:Ct��•�,"TI �F ��'
T 'a P�Au!DRPA}�'W�1 �ds= ;. 1 t`! �r G1~NER .INFQVIATION
4 �, AtPGd as pa •Afthe iiuspecti n cs r oo ' r'`•;
# y +R T Ia,pW�n
q puwped determined?
{; ”`
x'11++1�,.��1 �7��k�rn�RRrISSIxv�'Y
�� I vfaH.vrC+c ?� �R!�oA+absArpttaw Syste�pt(a(��,)'�} �: I r .. ' �•,
swgj.:k a
t� i .C' a I '�{ a 1 •, �7 t • Y �l i r A r '•
r � � v ° P y fl.�,"T�I�y"�?i`l��t�ri�1r�� In�}.�,y{)!;}{rid•.1s�s t��`.a 1F�- 'i •,, :i•{!.
„ � +� lAA1+ ttX Vie ttichn to �vi�.�pom9 records,if any)
� � 4 A A �'Atta�h a SPY of the current op 1400 and maintenance contract to be {ix
9?PY.Of ft DEP approvg ,, ,
4
0110 ;.date• ;�:
kAP +n attdsource of information:
_wheel a ri*g at the&ik Wes orno): I1
tytgga p•�{�, v�' CC tt i, �G
IS '7e' L JYtk Ct ft- tt IP � ai i St Vl ., 1.i•t r.11�1 "3Y :ti
4 it• iii t. t T ,( (grid a•a ,� � f t � ¢t �, h - i
1" 6v;ra��dr<� 7as i t 'Y1
tp �r ( e4r > f
l�'
`C�i} r }°�ayiat fi�gy!$ rt�Rwt 14Ji } =i y h tr t
-ILis
'Q FJOIAU-INSPECTIOn FORM,;-NOT'FOR VOLUNTARY ASSESSMENTS
NJ$ URFAC'E SEWAGE.AISPOS
} AL'SYSTEM INSPECTION FORM
INF.
SYSTEM
ORMATION(continued)
P
• " t ,r ;�� � �t�Y �4� >s,K �',"fir` .. • r: >,�,.
, 3p• I r
'Ins
tl
INi.,r� ���yt�kA��wLy }, �-fit t1 f y i+ ,j, ( . r _+�•,
{ tf..a... t T, •e"D�".�.,aryl. Ir r aE tih
1 ' �y tF'�'�'E�'o�►' 1�1) �e{lli!-ttl.�fG�zlt.t+� ..�'. ..t ' �1,
+ ,,� 2(„M« r• r �,iy .. . ' ( k`;'.r q.}y4.t,c i�sN 1
" Qf
-91m-
AM
-�FrtgQ'PV ,
water -- .0 Otlt4kG lain :
P supply-yell or suotion luf. Xp )
r yrs" i fi " s,(an condition OU00%Westin evidence Of.�. , ; S'
4�J1 t 1 { leakage,,etc ".
kil.µAWe �r.
a ] t?i li7J'})r'++Q7,! r +t1 �r s. ,k `,r�r!_� f i{ _ �.
�. � ' �.
i T'"L' Mw YM site
).
.E '}j7
` �pttx'•�` R
laings& polyethylene
f--- P �
�l 'r
Is age.Fouf wd by a Certifiicata of Compliance
(yes or no):_(attach a copy of
-77
1 S -
. .
ahs .'C �'`'rS" 1 � Eo bQOQ10
tee
orr e•
f:Otltlet
't� R ►t4P
FIFA to top of outlet teo or144 bade w, ,
A� �, b.Qf scum to.:bott4m Qf oK4l,„tee o
�� ';���, 1Y;�&N,�,I�Iq }�s:d!oter�una�; , • '•L.`,
`��'��Rl rtB'r4r �Oti�rRt�i,tiaa t,� .'A.:�f trgl��uAhl t{��tvhar�eYidence
. .)d. uRMPMS reommedoAs,Inlet64
o oo ; :e { ..
enition,stuctuaintegrity,liquid levels
of ekage ee
o�f`✓
i r Y
'}t1�1} 't �.R �{ n'1`.gt•G k ct�E{SMf �r 4� a�...i r- I a r:+.
'� a '. ' • r t ,t t. .
f�.t•g'�al�R � �'x�,{{{�t (k ,�)�3?hR� �WMI�Iap��al'lltvl+�},1��'frr.lat�tl�ili�'1•�1Jts .. . ,��,.
9f
;0A
tees}}h�(r. 0•1 eK'r i•1IMM Mte 'lNetal�'� y 4'i •I i,�;
}a+t+l�t f.;� (eacplt�•'� ';;y ,~t ., -•*-- ,�„�. �,.,_ ,berglass,,,,,polyethylene
�LAli'AN
T
yh c2r °rr sd�lim ] is ak1 „9.
} ,.ry l '•
y^' n .����, '� '•« �l #'�M SRP MY1�'Rr.�..^.T Y/ Y1MN�thl� ! f - { f�a'Y(y�..
s� �Q(�1 k1 b�ottot of palet toe o�1baffle•
9 M� �,!�� p'•'*""t �,, y S�� ' ,�,tp ti`xE.{ � ?� t•,L ,��:l�.t-. � .,, ,, a+f
P
1R�8 tgtnendatipns;`utlet,and outte r o
� v#t►evidence Af leakeg�`ek) .a r bilecondition,structural integrity,liquid levels,,
I Fa;
`I ?� F�,d�'7rw j$k y'4t L`u+t�rrf,«tnY v i�'i I .. 1 • •
v y tir�
' .� ti �i rr a : t •a a.
N
p � � t ■S t`t ' � �t!y ° � t yr `� + p „ , t t f � rr:;
D . t x'Ifr
:'�•diMfi '��'t�I heF t +t to +r Gr v i�` -fid+'{ .a
”
�i^jy�wtt}h�cai
� jffimv!#
P• ., }bP> {rr � 1 d V'd t , p n 'fk' r 4 e 'rt�' 1F �
`I.
4�y {h�� �N���hf' f, "J��`�`�7�, '�-y a u� � ✓(ra. -.i i -
aF
•
, t�sT Jt(ry<dF1 ? ,,
3:7 s"ai rs `t� >�NSPECTION FORM* YQT' 'OR VOLUNTARY ASSESSMENTS yro
y n 4
SiJESI)RFACE SEWAGE DISPOSAJ tiSYSTEM INSPECTION FORM r
F
PART-CM
SYSTEM INFORMATION(continued)
' r
-1 •dry ,.Y &=A
1 (al'tp 34 S4 y�.f, k l •r' V���.� f.'7. `,r.F
p4 411,
^i�°%.
lr - , r 7 ' .'rhe � r.r'�� ,11�..1, .:•, .�'
_ �' I4II.DING T � (taalc mud be i
„'k PUMped At time of inspectionVocate on site plan) ,}1.
t ��' �rk, �_'i'`p!�`�n�" ��'h'r7+t ( ,�r t},rls{F°;S � a<�,,.�4a ' '�• r'
V.- �fr 'fy„ /�}� ��.a J^1�/��y}moi}.,[. •• " r,4:r''. try ''�: t ., . . p.:- .}`Q..
•_,.�fibo polyethylene other( lain
� '�� . exp ):
1
}ly 7iw1 ✓, ra �grr16lt. 17: - ,
•ani / �Gll( *' t; lA wow
mg Order(yes Or AO }
} � +1sIPA"Alcp�p�;
4jr �L y S 111 ,l a �An IAF"farm lee BWI etc,)•
d1a r^ni 1', r ♦ :. .,,..,� '/t3y 1('."' " v h �ie
kt•1ryk7SC�rpY'k,�°�t,�jjtn3';r 1 1 rp{
�r�� t4�%v 'Ir{�t+'ihi�at3<R�{�`� k 'r� � „ V7'�� t•f�� aelL r ' 71 � t.( 1 �:r�l.
1 4 i �'dI4 _^ { (t ,Yl eYe�t'.rw•n!r.I o
plan)
Petteedxlocate Oa site lan
a
G J Y0�1Yg quoit
b4 is level laid dl$trib OA t0.outlets
r�
Of equal,any evidence of solids carryover,any evidenceof !
y,,t40. }.y "'"��•M.Is..i' •r 1 '
'
uatrt, iN!!< 7 Fp A-y, rlah�. Px, f.).r ;. , .
'f 7rnAs t9`` 4t a g} y,,, .• tij%�.
IT
!;jtPk�' p"�.,,x'n,,R��rTj `tS FIA�'1.3jf� Xy��k{r�kr r,! r,fi�f lr 14iJ{)J}1�4 iA 1 1F% ti J? il}a".j ;+Z+i.
.• �` .�� 15''' „a' ,�,��Oa site lan 'i v,J'' j r !..' ' . . A,;
�' y b yt � N�' �, `���,�+�xaG�y ,��,�,�.ti �'If'tr .r S. 4 •P � ! i' } .. !����.'
(Yes
sA wg OrdQ(yps or
01. um C s'
Pump balaber�condition of pumps and appurtenances,etc.):
'
�•'k ��"3 SQ'`��'"1�6,(�r`f��i�s}}',,}�,yy"r'4�a <a�� �� } t c' ti " �1 ,i '.
0",
< 7 � �
{i7 #sR
�t t 4dl a S ptt Ht r'7} ,f
rrlt r':t '�31i�. J�' ( 4
t }t S r 4i7y 1 #Y r tirt r f 5 r r. t
{ t, !
�
� ��' �3 �p" t���,`ti7M���cl�rr}.St y.r1 t.ft:J i.'t 13 �te �1 1".' r •��
#t}tJlH1l�17i�d
' J E tF�Y�aF't
1 j�4 it i i77t..;,t
Y Ja,�'�4"{,^tar�R r:M rt'�7�l t, n4nS,V v r rr r 4.:�•,a y� ! 1' T ^7".-. ._. '. `1` +3•i�
•1'� Y�".�clgM.�j.''�-r'..`M". b?'� T tr*•.p+b.•'T..�., '7
j r 71�lf•y'�q�!�'1 pit' ^�e'tT'r+^^�,y,�,•a'r..r n +r.•..y�.,..,. 5�,,,,,% , t ' ;:{
5 � F
� ppV j¢'t��Klt>.CYh.:i.� 7 Yti' y- ! 1 J'7 11f � � t7 • 1 .
a �l t 1 rlwTayyt< 4 �rl+'r is itt ei: ;r' ' r i� h.
t.
1 s t" st r fMi,�?A qy f d.�rsa'i<r {J: fli .yka'S 1N tt` � tr
i l r13 ,y J I w, H•i f, C,j4M'4� _ :t d. +t r".dr { i i
4fd A x
t,f w r i1}( r rc•.v �u .7 7 C 4y I - :Idl�.!.
� ,.ytll{ 7�C.a'Ed`•�+�ST. '�a{,i"
I1� i°1 eR
rt' r n! Tka P rsCIAL
5 ' G" 'ION:F�IRM
NQrTOR VOLUNTARY `.
f� " , ARY ASSESSMENTS
a i r•��p h��s'� Fj r Y �r I !":�� 1aSU,8S; F
NAP"SEW.ACE)DISPOSAL SYSTEM INSPEC'T'ION FORM
< r s�D
PART.'.t.
%�.��'"i!'t ?•s ti fib s{''�y r n�i „ i v. � `.
SYSTEM INF..OTiMTION(continued) t
7777
QN SXST�III(SAS) (locale i
pliiACICaY$t10II not CegYl/'ed)
s aFf'pF 9W}h .(iC r
s��rtv"4 ''.�a�71i f•r{ttµ4 r; { � ,, ;t _ •�•
.� ,r�F{�t�•'``�,,yy ,`�`t��r�'7P'IE^����?}�f'�,{!�`'�II,.7r �E {.'.1 s! `A��.��xl�?t 1131 .. ii
�w c nrFgt i.�'tiY + n+,,,;3 ,r�r•i." !. ;,r 'SrlrlflY'i w., f..
17T1.4Fc,,vv �I
"Of} `�1++CCC�S
Fik�s.1�,�tW�i
I �., ♦ i �`Yl?TnY{ YYfr,"_� t .3(.1,� f ��..
l' M�MMIF�►. 1 'fly;.
04100Pl ..Vti
r y TI �A••�- �!!ww•�Y�w•
14 'k'a�rY'` 1 NPM�l�1M.r
ys m. 1ype/A t11e Q
P$of�lydraulici failure leY 1 of
e pondmg,damp soil,condition of vegetation,
rk sst;F'9'is.1,q'•.ru',-.(�y � lli aY, u �I, 17 ,1�: I �/'
e 11 �A,Y�iCj{i�ixral'
ty �� �• l ice, t
{{s int."},h � PY.Q1 by r it e�}A M1°•16'^l�R�l^4'� i'f T p( t�MMVt M7 p'•^T�`�•Mle7rf TeR�j"��!wQDxloM•ion kS1K`plan) t.
1; v
iOut f
;, `� ''"'�����l�d tQ WIOt uaYert: ' i a ti t'•,j r �, ',
�
r F
Ow(yes or,no): ,
r rrll {,
-of
391sipsof by�raul,p fature,level of ponding,condition of vegetation,ek. R
q���!^ii'i!r�))1�'f.Y,>r7 �' 1 a rF iy, , 4 t. n, - � (,( ''•.
i h Y
t ,, f}.7i a�" 4��r+lei 1r���s,,✓l i t�AY� r ,•�-..
ra g yule f 4{ AP 1 k.
.�idi,'
R • !�R'M A,l,�n,[� rs+,t{C a fir y ..�' y 4�1;1';'t�gi4 �S-�.�� 41
rlt�r
A{� ; 1 !
t�..
� • !rF `S 4 xra w.' r St
'.1! �;�s. `• �r= 1 I �6 � ' tk 1`' 7 .,�
h kY � •Tr, ' "p'�C ,gyp , 1 _' .. � r� et '', •, i.1 x��•,
+ ' W HiQ of `rltttY Pr ponding, 3'
is yK�,CCy j Y ,level of ndin condition of vegetation,etc.):
�y�Ft�a a4`�ti i8ll» s777,
9
Y�r�Y� ���� ��i'sn�°�i��r�Ni�}}entry, ! P , , ' 1 ��•
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PART C
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4bser`+e site(4buttiu /
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VATER BILLING HISTORY 3178284-SCOTT SIROTA METER 81:.3172264 m
121 FOREST ST
-----------
1 FEES TOTAL
8 CYCLE -SERVICE- PRIOR CURRENT USE WATER SEWEii
1 2890-13 18/81/1999 2816 2185 -4&9- 242.97 6.60 0.00 242-97
2 2000-23 01187/2080 2105 21#►2 ik37- 181.01 0.06 0-99 181.01
3 2008-33 04/06/2088 2142 2171 * 29- 79.17 9-80 9.80 79.17
# 4 2800-43 06/21/2008 2171 2157 A 26— 79.98 0-00 0_.00 70.98 z
5 2Q01-13 10/04/2000 2197 2231 * 34-- 92_82 0..88 11_110 103.
6 2d01-23 01 64/204" 2231 2257
26- 70-98 0.00 11.00 81.9 x
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=REVIEW CHOICE i1 or CENTER? ME HISTORY:
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BOARD OF HEALTH
No.Andover, Mass .
SUBSURFACE DISPOSAL DESIGN CHUK DIST /
10T #
APPROPED - D=_q: 5 DISAPPROVED DATE
Provided: Reasons:
Title V FAIL OK
Reg 2.5 The submitted plan must show as a id niamm:
a) the lot to be served-area,dimensions lot #,abutters
b location and log deep observation hoes-distance to ties
C location and results percolation test. -distance to ties
d design calculations & calculations shi. ng required leaching area
(e) location and dimensions of system-inc74djng deserve area
f) existing and proposed contours
(g) location any wet areas -Athin 1A0, of Sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within ] i0 1 of sewage disposal
system or disclaimer
(i) location any drainage easements vi, do 1001 of sewage disposal
system or disclaimer-Planning Boaru finis
(3) know= sources of water supply within 200- of sewage disposal 8
system or disclaimer
(k) location of any proposed well to, serve lot-1001 Xoom leaching facility
(1) location of water lines on property-101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by lax to prepare such plans
Reg 6 Septic Tanks
-- -- (a) capacities-150,% of flow, water table, •:ees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground s7,4= ng pool
(d) 25+ from subsurface drains
Reg 10.2 Distribution Boxes
(a) s pe greater than 0.08
Reg 10.4 b) SUM
P-10413D OPr►F .i�i-� r Z FEZ 57= _
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DISApP) oo\jF
F[k)4L APPNOVAL D,o��
�- - APP)�ovVJG
Address_ I 1 a 57- SJ _ Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes: T
action Document/ document/
Num. Action Department
B�rilding Dep
Board of Appeals — Board of Health — Planniing Board — Conservation Commission — artment
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DEPT, ,47 ReOBE CW)e/ST/,4NS6N EN6/NEED/N6, INC.
NOTE. TW/5 PZ-,IN /5 NOT 4 W,4,ee.4N7-Y //4 A-ENOZ,4 .41/E.� A41/EAlli-L, /YU.
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kV TE2 rcL EI�4 T/ON 1 y 7,50
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DEPTH ,4T P,eOBE C1le/ST/,4NSEN EN61MF INCIO /NC.
NOTE.- T�//S PLAN /5 NOT ,4 W4,ef 4NTY
//4 NEN02.4 4 VE., f,I,4VE�eA11Z-L, A".
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OF THE LOCATION OF TIE EX/STING
ST�E'UCTU�ES.