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HomeMy WebLinkAboutMiscellaneous - 1216 SALEM STREET 4/30/2018 (2) 1216 SALEM STREET 210/106.A-0182-0000.0 BOARD OF HEALTH , No.Andover, Imass . SUBSURFACE DISPOSAL DESIGN CHEM" 'IST LOT I C) APPROVED DATE 7 DISAPPROVED DATE Provided: Reasonss Title V FAIL Ob Reg 2.5 The submitted plan must show as a minim m-. a) the lot to be seared-area,dimensions lot #,abutters b location and log deep observation ho.-es-distance to ties c location and results percolation tee-,s-distance to ties d design calculations & calculations sowing required leaching area (e) location and dimensions of system-in luding reserve area f) existing and proposed contours (g) location any wet areas within 1001 o• ' sewage disposal system or disclaimer-check wetlands mappin, (h) surface and subsurface drains within _-*I of sewage disposal system or disclaimer (i) location any drainage easements vithi-A 100' of sewage disposal system or disclaimer-Planning Board files (J) knokn sources of water supply -4age disposal a system or disclaimer (k) location of an,,- r,-- -thing facilit (1) locati TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER&ADDRESS SYSTEM LOCATION k i m Cc-ms+en�i o,)Rn (example: left front of house) Z 1 k 5ai-m.&, q- DATE OF PUMPING: - Zq-oz. QUANTITY PUMPED 1,5o d 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) SYSTEM PUMPED BY: _ c�p��c-ct�5 c�f�a c�e►��i c _1 +1c COMMENTS: CONTENTS TRANSFERRED TO: _(fir, LnL")rence cS'Q,n1 a-c!4 i t�ic- i. 0 2 a 1 too-DO AL Z07- Lor 13 Lo--T !s � l k i �00 y iZ o �b© �4 ALc yl�`r`1• ✓1 �. 5w)pe REQUXE,�ENr a f , C150�� 150 DE3/6N EcE114TION ,4T. . .. ... . .(TOP OF STONE) _ ... . . . 7 So EXISTING aCWTION 47 . . . .. . . . . REQUIRED FILL = ELE�/.QT/ONS DEsI�:N As 30W- 45 BLI&T INV PIPE OUT OF,UOU,SE 1 y%,y.0 INV P/PE INTO T4NK /y g. ya SU,B '-sUjeF,�CE ��S�OSQL INV PIPE OUT OF T,4NK /�i',�, bS /�' ': •' SYSTEM INI/. PIPE INTO D. BOX INV PIPE OUT OF D. BOX y��� �v� r /N INV END OF PIPE ,J/, =' ' 5�7 as .� FOR GVATE2 EZ EV,4 TION z /F E a, Z- 7- )o' ,4 VE2A6E STONE 5C.4 L E= / '_ y0 D.4 TE: 6 - /,Z - R DEPT/I ,47 P,eOBE CAIEI,5Ro4NSEN ESI/61MV INC, /NC. NOTE: TI//S PLAN /S NOT ,4 X14,e� ,,4NTY //4 XENOZ.4 .4 VE., A4VEPll/L L, hoU. OF T/IE SYSTEM BUT A !/Ee1F/C,4TION Of T/1E LOCATION OF TWE EX/STING F-IuRD of HF4LTi-I nor /5 SWL6,Al w� E �? -7 �7 Tbc,ynl ❑ WEc.L APovCD C— --- . SS l/ StPT"t G Sy S 1�� list C-,r.� . �PPi�©vED Co�vfJlTio _ �►'sApobvEv 1416 R�4SoNS r ��- � StPT"(C SYST�ivl t�SiA I.L,Q"('io�1 C)"V4Tt01"J JNSPi�-Gi(Oti 94rG 4-r'7462 ❑ FAIL FDNAL I Q5P6—�---long 4PPROJE +4��IT�p1J,QL, I�St�x.j(ON5 �I►=A'`'Y) �SAPt'�ov�i� parC R�So NS , FwAL APPROVAL orlon Boyd & Company., Multiple Line Adjusters & Surveyors Established 1926 TELEX NO 466111 CABLE:BOYDCO ADDRESS REPLY TO: c 19DON 130,yil q ,�.� r 4a i,,,r i' Form of Notice of Casualty Loss to Building 11 , `tet..,, tl ; Under Mass. Gen. Laws, Ch. 139, Sec. 3B LAWr, �Av'� FNCi ST. 0184) To: Building Commissioner or Board of health or Inspector of Buildings Board of Selectmen „/' q/✓V���� /1�SS � addresses Re: Insured:_ �'i/ �!/� � Qi„ Jf-✓L►'1 ( ��/V L �. Property address:--/ 2 f t / /' a Jam- /1l► �r Policy No.--6e9q7Z"Z / /= Loss of M z 7 19 File or Claim No. Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass Gen. Laws, Ch. 139 Sec. 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. N Title: On this date, I caused copies of this notice tZbsetto the 7n ;med above at the addresses indicated above by first class mail. Signature and date Mt M. MASSACHUSETTS CONNECTICUT NEW HAMPSHIRE VERMONT MAINE RHODE ISLAND O Boston Lawrence Bridgeport Claremont Brattleboro Augusta Pawtucket NA AL Barnstable Pittsfield New London Gorham Burlington Lewiston ASSOC1ATON OF Brockton Salem No.Haven Laconia Montpelier Skowhegan NEW YORK 11,"KNOFNT trrc. Fall River Springfield Stamford Manchester White River Jct. S.Portland Utica WAAAN(( Fitchburg Worcester Waterbury Portsmouth DJUSTE W.Hartford 2 7 3`T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO Address of property 1216 5Pi- .57. OF /ti r1�,' DO�;� It Owner ' s name MvD' Sr,I11,LEY Date of Inspection PART A CHECKLIST r ~ Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. "� None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period . Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components , excluding the SAS , have been located on the site . The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, ' material of construction, dimensions , depth of liquid, depth of sludge , depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. uAL 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential Ll number of bedrooms 3 number of current residents garbage grinder, yes or no 5 laundry connected to system, yes or no N seasonal use, yes or no If nonresidential , calculated flow: Water meter readings , if available: L rrc-�.t Last date of occupancy GENERAL INFORMATION Pumping records and so rce of information: / 5.sS System pumped as part of inspection, yes or no if yes , volume pumped _ 15cn Reason for pumping : T % 1N> -?ra t N T 2! 6 ,2 d r` T4M,< Type of system 'L�_ 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) Other (explain) Approximate age of all components. Date installed, if known. Source of .information: Yec, Q-1 0 O A_ Sewage odors detected when arriving at the site, yes or no �tS- 3 .7 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade : 8 material of construction: concrete metal FRP other(explain) dimensions: )You C,Ar L, sludge depth ZZ2" distance from top of sludge to bottom of outlet tee or baffle 1„ scum thickness distance from top of scum to top of outlet tee or baffle i distance from bottom of scum to bottom of outlet tee or baffle o ,,ments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in' relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) -Ani i4, 0 w, DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments : (note if level and distribution is equal , evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) P Uflp CHAMBER: (locate on site plan) pumps in working order, yes or no Comments : (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) 10 �s 3 "7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible ; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length Z s✓ehr r � leaching fields, number, dimensions overflow cesspool , number Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) F �S c.0 c CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs, etc. ) 1]. q..5 .3 -7 ' SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' f . �i r DEPTH TO GROUNDWATER i u depth to groundwater method of determination or approximation: 12 37 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes , no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1%2 day flow? t' Required pumping 4 times or more in the last year? number of times pumped fZ____� Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS , cesspool or privy: 1 below the high groundwater elevation? IV- within 50 feet of a surface water? AL within . 100 feet of a surface water .supply or tributary to a surface water supply? N within a Zone I of a public well? s within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? I within 50 feet of a private water supply well? I _ less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysiE for coliform bacteria , volatile organic compounds, ammonia nitrogen and nitrate nitrogen . a 13 11 ` 37 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector 3e^jAv­kv C• c� c w J Company Name ��W rtiG-i0ti'0 c,4.; <,1A,/ rZr� 4-_ sc2�,;c�s X"e_' Company Address , Certification statement I certify that I have personally inspected the sewage disposal system at this .address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Chegk one : ✓ I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector ' s Signature �l ,74 Date G-riginal to system owner Copies to: Buyer ( if applicable) Approving authority