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HomeMy WebLinkAboutMiscellaneous - 1212 SALEM STREET 4/30/2018 (2) 1212 SALEM STREET -- 210/106.A-0181-0000.0 RECEIVED Commonwealth of Massachusetts W City/Town of No Andover 3UL 07 :2014 a stern Pumping Record TOWN 0T NORTH ANDOVER HEALTH DEPARTMENT GM SV• Fora 4 DEP has provided this form for use 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 form, 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 within 14 days from the pumping date in accordance with 310 CMR 15.361. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1212 Salme ST key to move your Address cursor-do not No andover ma use the return ------ - -- - kse City/Town State Zip Code 2. System Owner: Name rein Address(if different from location) City/Town State Zip Code i Telephone Number B. Pumping Record C 1. Date of Pumping — -/ - 2. Quantity Pumped: Date Gallons 3. Type of system: 0 Cesspool(s) Z Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5, Condition of System; 6. System Pumped By: Name Vehicle License Number Stewart's Septic rvice Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of ReceivingFacility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts W City/Town of No Andover System Pumping Record Form 4 M DEP has provided this form for use 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 form, 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 within 14 days from the pumping date in accordance with 310 CMR 15.351, A. Facility information Important:when fining out forms 1. System Location: on the computer, 1212 Salem ST use only the tab key to move your Address cursor-do not No Andover MA_ use the return — _ _�—..__ _ key. City,town State --- Zip Code - 2. System Owner: Hanle Name __ RAO Address(if different from location) City%Town State Zip Code - Telephone Number B. Pumping Record 1. Date of in Pum l p g bat �- ---��- 2. Quantity Pumped: ----T— Gallons 3. Type of system: [] Cesspool(s) peptic Tank ❑ Tank Tight g � Grease Trap 0 Other(describe): 4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? Q `!es No 5. Condition of Sys term; l6a t„ti 6. System Pumped By; Name %.phicle license Nu ber ty��FctH W ENT . , r Stewarfis Septic Service. TCW CTN��pAR fM Company NEAL' 7. Location where contents were disposed: Stewa Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Sign , re uler Date Si uraf ReceiV a Date t5form4.doc-03/06 System Pumping Raeord r Page 1 of 9 FORM U - LOT RELEASE.FORM t '"' jVSTRUCTIONS: This form is used to verify that all necessa a royals/0ermlts=from, Fav—it--ill will resu] g 1 y p Boards and Departments having jurisdiction have been obtained. This does n:ot relleue. the applicant and/or-landowner from compliance with any applieab(e or.regwirerrlents ,— CANT FILLS OUT THIS SECTION****** ********* ** APPLICANT Vcw Cj �� PHONE - -� LOCATION: Assessor's Map Number _ PARCEL SUBDIVISION LOT(S) I STREET ST. NUMBER 17-1.Z.- ********�t '`***""OFFICIAL USE ONLY RECOdVI NIDATIONS OF TO N AGENTS: �-y ? CONSERVATION ADMINISTYAOTOR DATE APPROVED `7 0 F DATE REJECTED COMMENTS 9 �t �e �tence.. — D " ' 6 1 - lie-Ca�iSlcccrJ.i� cared lYO1NN PLANNER DATE APPROVED DATE REJECTED Property iOMMENTS a DIN SPECTOR-HEALTH DATE APPROVED ' DATE REJ abject _ I knowledge EPTIC�iI ,SPECTOR-HEALTH DA' PPRO 1 {: DATE RE CTED OMME:NT'S C ea i, , r 77BUC WORKS'-SEWER/WATER CONNECTIONS : '>i .r., ' DRIVEWAY PERMIT E DEPARTMENT EIVED BY.B'UILDING'INSPECTOR DATE { sed 9197 jm ' •yw g10RTH TOWN OF NORTH ANDOVER S« J ` PUBLIC HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER,MASSACHUSETTS 01845 SACHU`�E Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 August 5, 2003 dl, / D.J Edward Hanley c� 1212 Salem Street North Andover,MA 01845 U" Application for a building permit for an addition 1 De Mr. Hanley: The He Department has reviewed your application for a building permit to construct an addition to e existing dwelling on 1212 Salem Street. Unfortunately, under current Title 5 regulations the xisting septic system does not have the capacity to handle the additional flow for your proposal, an would have to be upgraded before the Health Department could sign off on the building permit. I have enclosed some genera ' formation concerning additions and the septic system repair/upgrade process for your view. Please call the Health Department at the above number if you have further questions. Sincerely, Sandra tarr, R.S., C.H.O. Health Director W/enc. Cc: Building File Why do I need this approval? : The Health Department must approve all applications for additions to houses served by a septic system before the Building Department will issue any permit. This is because there are several things that the Health Department must check, namely: • Does the addition meet setback requirements? • Is the septic system working now? • Where exactly is the septic system? • Will there be more flow to the system? • Does the system currently comply with relevant regulations? • Is the system large enough to handle any extra flow? • Is there room enough on the lot for a new system and a reserve? All these questions address the problem of whether the septic system is or can be made large enough for the maximum number of people the house could hold. An addition of any kind when there is a septic system on the site is considered "new construction". What do I need?: You will need to submit floor plans for the proposed addition along with a complete floor plan of all floors of the house as it currently exists. The two plans should be in the same scale. You will also need a certified plot plan showing the outline of the existing house, the proposed addition, the location of the septic system, and any wells or pools on the site. These should all be to scale. It is also recommended that you have your septic system inspected by a certified Septic System Inspector. It is important that your inspector checks on the size of your septic system -as well as how well it is.working. . Who do I see? See the Health Department if you cannot locate the septic system; there may be a plan on file. See the Zoning Officer to find out if your lot and the proposed addition meet Zoning requirements. Check with the Conservation Department to discover whether wetlands will be a factor in your project. Then submit your entire package to the Health Department for a decision on your septic system's fate. A Civil Engineer could help you with this process. How do I do this?: To start the process you must first go to the Building Department and apply for a permit for an addition. You will pay a fee and receive some paperwork. You will probably have to go through the Conservation Commission process if there are any wetlands anywhere near your project site. If your site is located in the Lake Cochiewick watershed, then you should check with the Planning Department to see if you need a special permit. If you have submitted your application to the Board of Health, staff can be reviewing it while you are going through other departmental processes. A final approval and permission for a building permit will depend on the approval of all pertinent departments. Other References: • 310 CMR 15.000 Title 5 (You can download a copy of Title 5 at www.state.ma.us/dep/brp/wwm/t5pubs.h tm) • Town of North Andover Requirements for the Subsurface Disposal of Sewage • List of properties in the Watershed (in the Community Development and Services office at 27 Charles Street) t DelleChiaie, Pamela From: Starr, Sandy Sent: Tuesday,August 05, 2003 2:27 PM To: DelleChiaie, Pamela Subject: 1212 Salem- letter& info. Pam, Please print out the attached letter&brochure, add the colored brochure"My Title 5 Failed.....", send to h/o and 1212 Salem-no addition.doc distribute rest, (also one to my chrono file). Thanks. 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ , d DEPARTMENT OF ENVIRONMENTAL PROTECTION WN OF NORTH ANDOVER/ RCAEJ OF HEALTH TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner's Name: Edward Hanley Owner's Address: Same Date of Inspection: 6-28-03 Name of Inspector: (please print) Paul Cardone Company Name: Septic Compliance,Inc. Mailing Address: 447 Boston Street'Topsfield,Ma.01983 Telephone Number: 978-887-8586 CERTIFICATION STATEMENT 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 15340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority . s Inspector's Signature: Date: Z, uL3 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. Notes and Comments this inspection was performed in order to put on an addition ****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. Page 2 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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. Answer yes,no or not determined(Y,N,ND)in the 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 existingtank is replaced with a complyings tic tank epas approved b the Board of Health. septic PP Y *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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: Page 3 of 11. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and-Public Water Supplier,if any)determines that the sys-temis-funetioning 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: Page 4 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N/A _Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No any portion of the SAS,cesspool or privy is below high ground water elevation. N/A _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP 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.] No (Yes/No)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. You must indicate either`yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page 5 of 11 OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,.or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes-Partial plans_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? Yes _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Yes 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: Yes no No 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)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 5 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Occupied COMMERCIAL/1NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION - Pumping Records Source of information: According to the owner system is pumped every year,tank was pumped one year ago. - Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: 1250-1300 gallons--How was quantity pumped determined? Pump truck tube Reason for pumping: Routine pump,to check inside of the tank for any visible cracks or leaks TYPE OF SYSTEM X 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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 17 years of age Page 7 of 11. Were sewage odors detected when arriving at the site(yes or no): No OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 BUILDING SEWER(locate on site plan) Depth below grade: From top of foundation down to vibe 45" Materials of construction: X cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): All in good condition. SEPTIC TANK: yes (locate on site plan) Depth below grade: 2' Material of construction:–X—concrete_metal fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5' 8"x 5'5" Sludge depth: 3-5" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 1-2" 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: Septic Div-Stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,.structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): We recommend tank be pumped once a year,baffles in good condition,liquid level was good,no evidenced of any leakage. GREASE TRAP: N/A (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of a leaka etc.)::) Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-30-03 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_Appeared to be even 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.): Ran a camera to the d-box PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1212 Salem Street No.Andover Ma.01845 Owner: Edward Hanlev Date of Inspection: 6-28-03 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan,excavation not required) If SAS not located explain why: Type . leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: X leaching fields,number,dimensions: 1 field approx. 12'x40' 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.): Dry No None No Grassy elevated area on opposite side of the driveway. CESSPOOLS: N/A (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 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 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1212 Salem Street No.Andover,Ma.01845 Owner: Edward Hanley Date of Inspection: 6-28-03 SITE EXAM S1ope0-3% Surface waterNone Check cellarDry No sumo pump Shallow wellsNone Estimated depth to ground water 10+ feet Please indicate(check)all methods used to determine the high ground water elevation: X Design plan owner had—went to B.O.H.nothing on file Obtained from system design plans on record-If checked,date of design plan reviewed: 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: All liquid levels were good soil dry_ no sump pump,According to asbuilt no water observed A141.00 The addition they areplanning to put on is on the opposite of where the septic system is. if 4 LOT W Peso ,��• 4 f ' AN / z t 1 F1 ' oo A D X33 i CPI OpE i i (/50) X - /50 — - . .. . . . . . .. . . . . . .. . . . .. - - TOP OF STONE) �•�� DE.516N EL EvId T/ON 4T. . . . ... . .( - .. . . . ... . ... . . .. .. .. ... Ko,zae�s /V� II . .... .. EX/ST/NCS ELEI/LJT/ON .4T a 4 r tx.-:v.QTioNs oc5iGw QS BUX T INV PIPE OUT of!-/ousE 1 S0.7�1 VB INV P/PE INTO T�JNK INV PIPE OUT OF TANK INV. PIPE INTO D. BOX /N /NV P/PE OUT OF D. BOX I .� o RTH �p ovE-'R. INV END OF f'/PE FOS W�,reA No W�1ER 1 QR,U�.5 WATER ELC 4TION 1yr.00 yi•as R. SCALE 1 _ yO .D.�7, . 4 VERACE STONE '3 r� ,4T P,eoBE Cf1R/STX.4N54FN -ENG1Mz oEP 114 �ENOZ,4 .4 VE.;. ,y.4�' ' ' /VOTE T1115PL dN /5 NOT 4 a/,4,ee,4NrY -' OF THE 5Y5T'ENI BUT .4 vER�/�N�N �F rNF /OC�lTION OF TWE' EX s FORM U LOT RELEASE FOAM t 'l G� 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 fro.m compliance with any applicable or requirements. ***************'**************APPLICANT FILLS OUT THIS SE- 44 APPLICANT 6J,� C) ( PHONE 78 aZ LOCATION: Assessor's Map Number _ PARCEL SUBDIVISION _ LOT(S) STREET 1-112— �1, '��' ST. NUMBER .)Z I-Z ********** ***** ****,.►**OFFICIAL USE ONLY****** **** ******** * RECO(VI lVDATIONS OF TO N AGENTS: I CONSERVATION ADMINIST-ATOR DATE APPROVED DATE.REJECTED t, a3 Q3 COMMENTS F9rijt 12eeae�c� Dg . 1���.Co,S-Fr�roL, TOWN PLANNER DATE APPROVED DATE REJECTED. COMI%ENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC 1 SPECTOR-HEALTH DATE APPROVED DATE:REJECTED COMMENTS ,e J LQ _77 Roof 5` c PUBLICWORKS'-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm � l i ► j l l j � l i j i i I I I I i ' 1 I I i I I I I j I I � I I � � f I � ' I f � ! ► � , ! I � f ► II I � , I I I I I / X11 � � ► - II , � I ! � ► I � lif � 11 � Ij�A III I If , � i ' I I Ili f I � ! I II � , � I i ; l I ISI ►, � ► � I I I it X11 i � ► I � I � Ifl1 � } Illi ► ± III � IIII I � i � ! I i I I I I { � I I i Iii II ` I o , I I ! I � iil l I � ' � ISI ► � � ! ! � � � � � I t � � � i � ! � ' � f i I � � f I ► f � 1 i � E ! i i � ( � f � j ' i � ' i j � � � i If I � � I � I I � � � rl ! I � , II I ► I � I � I � f � ( i ' � I 1 11 I I II � � I � � � ilt II 1 � , ! � � i I � � � 1 � ( � � I � � � � ' i i r � � I I � � `, { 1 i i � ! a l � , ! � I E i t � I � I � � � � 1 I, I f �. i t � ► � I f , If I � r I I t � E f c � I ► 4 i I � I � I r � ► c i I a I � f I I S i I ►�� i � � I I � � i ! � f i E � l i f � I ► � � . ► I % � f II � 1 I � I i i ` i a i , � EI � , � l i { l i l i � ► � I � I I i ( � � � li i � ( � CI , � , I � I IIt ii li , Ii � f ► I } , ' I ► I � ( � � ► ► ! � � I , � � II � 1i I � � � ► ► i � i ► � � ► � I � ! i { , I � .+ � 1 i ! � I 1 � � � I ! i � � ! ? � I l � C � l i " I � ! i � ii TRK �f\ 1� G" ,;l 1 - �' / r . .. . . . . . .. . . . . ... . . . . . . . .. `,. " CE!/4T/ON AT.. . . ... . .(TOf' OF STONE) = . . . . ... . ... .. . . . . . .. .... .. Nis +aNSFM E°L.010TOV 4T. . . .. . . . . 2EQU/1etD F/LL �. No;::isa9s ,t t oE51(�-N -4s a1-1/�T ,4•�. UfL.T YT of 1-10�15E 17-0 T4NA' )Z/r of TANK INTO D. BOX 21-/7- OF D. BOX10-74 _:f ': . RTNtc� otEL Fofc' E v,4 T/ON nb wA-rCA NO wA'rf-R �m p,BF-S STONE SC.r�C.E DATE• '" P/�OBE .. C�✓�ISTl,4�'V �1! E���/VLC�ie�/��,� � /Y /5 NOT ,4 l�f�,4 '�'4/VT Y //4 fCENt?Zl 1/E, ,y,4 J/� ;�,✓/L L, %Y7' I , M��`!'/? =s S.y�.�''T,!":©w . ..d'x/✓_T,;;.:>,:zAk�:�s/�..�.✓����i1:IsfF�..�.�.�_..�.u..��.'....,.,..,...,. �.m._......�_........>:t.s..y....,�.,'.",.m..__ti a.u::�ymr,._:d?.te.:�. r .i',h.'�"�E m�:�`a,�,^�4" �..a� ', +. q � rr� FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from y Boards'and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICA-NT r#LLS OUT THIS SECTION"""" PPLICANT��fi, / ��u�R� TIS le', PHONE LOCATION: Assessor's Map Number/ PARCEL SUBDIVISION LOT (S) 11 9;7__ / / ✓STREET P S4YJ°ml� `tT. N13MBEftZ�IP ® USE ONLY"***** ****************��*�*"* RECOMMENDATIONS OF TOWN AGENTS: — CONSERVATION ADMINISTRATOR DATE APPROVED G BATE REJECTED COMMENTS Lot- d TOWN PLAN DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED - DATE REJECTED - 7SEPTIC INSPECTOR-HEALTH DATE APPROVED r DATE REJECTED COMMENTS � �G76 1--Z,79�J 5 /�70If- 4/X5T A)6 &7 PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT ,/FIRE DEPARTMENT RECEIVED BY BU1L-DMG 4ISPE-CTOR DATE Revised 9197 jm I r fa e i I [� E ' 1 � , A + s 1J. Ll ( _ I 1 .. Cyt � �w t M � r I _ f . - t .' s C7 ,*F.� ""701 ql T b-A Z �4 hx/ ; -Z Z .�_� � t _1. # � 1 !r 4 I ,r 'S 1 I }�:• , rc> 2121 pdt / .: .... ...... -. .. ..-__. 1. .. �._..... .. ..- ._...� ..Ir �.__. , i i I 122. L OT 6 I,AT4, e /3 Dj 98 6 J. 00 711 CRE-5 / ..0 v f` �M1 •x ` 1 i R NO U - 9 a � �Y' IWn 3 >, LOT / 1 ` . . .. . .. .... .. .. . .. . . CERjFY T><,/G T T,�✓E" OFFSETS D//0/G S,�/ObYN ON. ;,t /S 20N/N SCOT t �t GN ' CONFOR�[�16 TO T�,!E ONLY GND GRE ZONING 8Y-LdwS OF TSE USED TO Z:5 OF N.,.qN.�Q PE�i�Ty L/CIES . TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 7' 271102— SYSTEM 1- d2SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: /i�L��!� QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTE 114 PUMPED BY: O L /� COMMENTS: 9M f2 ( v CONTENTS TRANSFERRED TO: FORM U - LOT -_ - � r ovals/permits from ���e� . ,is does not relieve TIONS: This form is used to V ei �4� ,TRUC 9 r 5 A or requirements. ands and Departments having, jurisdictioi applicant and/or landowner from comp)**, ***** APPLICANT FILLS OUT THIS SECTION ************************ iolol j L I -Z �7 . PHON E el PLICANT '� '"� PARCEL__-- CATION: Assessor's Map-Number-- _--- LOT(S)--- BDIVISION ST. NUMBER!—Z i REET:�Vl * *** F FICIAL USE ONLY"*, ****** i * r :COiV111DATIONS OF TOWN AGENTS: -: DATE APPROVED )NSERVATION ADMINISTRATOR DATE REJECTED , )MMEN TS 9 DATE APPROVED I REJECTED------------- D. J E )WN PLANNER DATE RE :)MMENTS DATE APPROVED C .:)OD INSPECTOR-HEALTH DATE REJECTED-------- L'"` � DATE APPROVED J N DATE-REJECTED L ' EPTIC I SPECTOR-HEALTH Au -OMMENTS . UBL IC WORKS- SEWER/WATER CONNECTIONS DRIVEWAY PERMIT =IRE DEPARTMENT DATE_-- RECEIVED BY BUILDING INSPECTOR Revised 9\97 jm C4iZ� of::' FICQ �- _ �5 R (,v �q� Sc��►�ty__ �T�c,�nl D WEc,L ,�P�oyCD]yJT'C SS SEPTIC SYS iEAl OESI6A �ppl-�O\)ev �Art� ljpmvUItiJ6 /Ovr`")of� r`/ < oOAJ ITiays �►5,4PPK�vE� 94 Te R�4SoNS ScPP c SV5TEM W S TA!LATI OA J C7U4Tco/J D/JYG D SS j� F14iL 1=rNA� l�ISPFGrIon� AVPITJOMAL, - INSP� , 10" C1►=may) R�So NS FKAL APPROVAL APPROVVJG BOARD OF HEALTH No.Andover,. Mass . SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # APPROVED DATE-�C� DISAPPROVED DATE _ Provided: Reasons s Title V FAIL O Reg 2.5 The submitted plan must; show as a minimum: a) the lot to be serve<t-area,dimensions lot #,abutters b location and log deep observation Oes-distance to ties C location and results percolation tests-distance to ties d design calculations & calculations Phowing required leaching area (e) location and dimensions of system-in 1ud3ng reserve area f) existing and proposed contours (g) location any wet areas -Athin 100' o ' sewage disposal system,or disclaimer-check wetlands mapping -- - - - (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements with n 100' of sewage disposal system or disclaimer-Planning Boa 'd riles 10) known sources of water supplywi„nin X001 of sewage disposal e system or disclainer -.-.----- .-- (k) location of any proposed well to serv.. lot-1001 Brom leaching facilil (1) location of water lines on property-10,1 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 waterelevation in area sewage disposal system (s) plan must be prepam-.d by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities- 50% of flow, water table, tees, depth of tees, access, punping I(b) cleanout (c) 101 from cellar wall or inground swi =i ng pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes F(a) -slope greater 0.08 Reg 10.4 (b) -mow FORM 4 • SYSTEM PUNTNG RECORD Commonwealth of Massachusetts'. ®off Massachusetts 3 � SYstenz PUMi2ing Record n� ystemLocation i Owner I )LIZ S4�e h Sfi �,`s�" T\-pe Emergency ❑ Routine Cesspc DI: No ❑ Yes ❑ Septic Tans:: No ❑ Yes Dzte c " Quanti5/ Pumped: (�yy _ gallons Pumping: BO RACZEWS permit S\ ster. Pumped by (Company): Conic is transferred to: Centl its disposed at: D2 -L Pumper Signarure Cc,nc !tion of systerrvother comments: DE3,�YPRO�`ID PORN " I:/o7/9S A e. LOTIS A-�S� d1 7- i IjA Of, II < a i4 (150) X /50 . .. . . . .. ... . . .:... .. .. sl DES/6N EL F!/ TION AT. (TOP OF .STONE .... . ... . . {� _ .. ►i is 1AMEN EX/5T/NCF Et6-k1dT/OSI/ SIT.. . 2EQU/SPED ILL No:28895 ` z�LEl.4T/O.5 it _ DSS/�N �S L3U/LT 45 9-t-A,r /Nle P/fPE Of/T Of 110USE j5o,7,c j ---- . /N,t!P/PE %NTO T4J1/K . .� �bJ� rled �Z-14 eF. CE � �D � r /NV. P/PE' ,OUT OF TANK F(�w'J�' {� 7"FAY INV P/PE'' //VTO 0 ,50.,Y 1N1/ P/PE- .OUT OF D. BOX /N if ` /NI! SND"'Of PIPE ti o v E R. FO/2 f GV�JT�`iC' EL C11..4T/O/1/ wArE No'why€R it - . .4 46E STONE p o PTw .47- AeoBE . 6MCIN //�/�, IN,C. NOTE. T�/S '� 4/V i'S /1SOT .4 , V,4k'�C'.4NTY 114 XEJVO 4 YE, 11,4XFAg1LL, /YJ.4. OF' T//E SYSTEM BUT .4 M5?e1F/C.4T/ O/V OF Tf/� L 0"TION. dF T/E E,Y/S T/�i/C STUCTU2ES: