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Miscellaneous - 125 CROSSBOW LANE 4/30/2018 (3)
,,125 . Crossbow Lane i r t Lot & Street ss)-::Ip LA-) Map/Parcel �d l CONSTRUCTION APPROVAL Has plan review fee been paid: NO Permit# Plan Approval: Date: l /fJd Approved by: Designer: f,4 U��%,e Plan Date: Conditions: Lz;' _5 5 i L I/ - J 0,1 `Pf 11,e TO S Y-S 7 M 6052�;e LJ TO GO ' Water Supply: own -__---- - Well- Well Permit: __Driller. I Well Tests: Chemical Date,Approved Bacteria I - ate--Approved Bacteria II Da pproved Plumbing Sign-Off: Wi g Sign-Off- Comments: Form"U" Approval: Approval to-Issue: YES NO Date Issued By: - Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: F SEPTIC SYSTEM INSTALLATION Is the installer licensed? NO Type of Construction: NEW PAIR -New Construction: --certified Plot Plan Review YES 1 --Floor Plan Review YES NO - -- Conditions of Approval from Form U YES NO __Issuance of DWC permit: - NO _.DWC Permit Paid? -- NO . DWC`PermitInstaller: - ---- -Begin_Inspection:_ _ . -;..;_.. S" NO - -Excavation Inspection: r Needed: hx .C _LPassed: _ By: ____Construction Inspection: ---Needed: As-Built-Plan Satisfactory: YES: `-- Approval of Backfill: Date: By: -Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: r7s 4 � 1 1 _.0 ,wary Club sponsoreaat-rn-uui a,... =. GassesUSA Voouu Qualify Membership in a Rotary club offers a number ofbE *Effecting change within the community •Advancing business and professional contact. .Developing leadership skills •Gaining an understanding of,and having an r Through Rotary International's service programs,, quality of life in its community.Rotary Foundat tional partnerships that help people in need worldv) more than 16o countries make significant contribl� globe. What does it cost to be a North Andover Rotcn-7 North Andover Rotary Club Quarterly dues ar, Fee is a contribution to the Rotary Foundatiq ■Rotary International dues $18.75 ■District dues 15.00 ■Meeting Costs including meal 90.00 ■Administrative Club expenses 30.25 Where and when does the North Andover We meet every Thursday at Brightview Sen! Street, North Andover on the following scY First&fourth weeks from 6:0opm-7:1 Second,third&fifth weeks from T V. Come join us and see what North Andover R� m https://us-mg6.mail.yahoo.com/neo/launch?.rand=8r{ s�-�11t �� 2S Lc,� 4 Page 1 of 1 UPS Answers Screen Flickr Mobile I More ®® © Susan got in search ew car. 3 yrs, volunteers,parents,work and/or live in .th our commitments to North Andover Prid' ' ionships and friendships that result from it business through meeting new people,gair our lives. We partner with other organiza ,lace to live and work, to build a better com Rotarians are business leaders who take an acti here munities while greatly e: ! conal and professional I contains a diverse gra 9 leaders from the comm 00� serves. roti ,F t.P community. -- I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �- '5 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be alter d i y way. Please see completeness checklist he end of the form. /� C. Important:When A. General Information REC—Enign filling out forms on the computer, � � •i' 201 use only the tab 1. Inspector: key to move your cursor-do notJohn J. SOUL TOWQ'O NORTH ANDOVER use the return key. Name of Inspector Soucy's Sewer Service, Inc. r� Company Name 78 North Broadway Company Address eUR Salem N H 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification 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 m training and experience in the proper function and maintenance of on site i P Y 9 p p p 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 ;nr's urther Evaluation by the Local Approving Authority 04/01/14 at re Date nspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 d ys of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town 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. j The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally dd 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): i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i P Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is N. ANDOVER MA 01845 04/01/14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) . Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is N. ANDOVER MA 01845 04/01/14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is N. ANDOVER MA 01845 04/01/14 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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? i ® El information 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): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: See Attached 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 Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENT Date Other(describe below): General Information Pumping Records: Source of information: Soucy's Sewer Service Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? GAUGE ON TANK Reason for pumping: Maintenance and Inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983 SEPTIC TANK, 1998 LEACHFIELD -2,,'17 V k Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 16" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. CitylTown 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 38" 2" 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 14" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is. required for every N. ANDOVER MA 01845 04/01/14 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is N. ANDOVER MA 01845 04/01/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 11 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.): FLOW CHECKED GOOD 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. i n n r Soil Absorption System (SAS) (locate on site plan, excavat o of eq uired : ) 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 30'X30'=900SF ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE 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 t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 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 ��✓ V` 125 CROSSBOW LANE Property Address — — --- ----- MARC KERBLE Owner Owner's Name -------information is every N. ANDOVER required for eve - _ _ MA _01845 04/01/14_________ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately MSP IG�v �J J16 x/sr/A/c- ScNcrar7AKK- Act pwsLLING R7 PAGK � Ex sT• EX lS% DEGt,' PoKGN �NO,fo viva f A a , � m \ 7-1 30"PINE 1 i I II \ P-1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 6' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 04/07/1998 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: DUG HOLE WITH AUGER IN REAR LOW DROP OFF AREA, NO WATER AT 4' ELEVATION DIFFERENCE 2 FEET LOWER THAN SYSTEM GRADE. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 } Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 CROSSBOW LANE Property Address MARC KERBLE Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/01/14 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 I I � I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i • Summary Record Card generated on 4/17/2014 8:14:51 AM by Karen Hanlon Page 1 Town of North Andover j Tax Map # 210-106.6-0116-0000.0 Parcel Id 17520 125 CROSSBOW LANE KERBLE, MARC 125 CROSSBOW LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until KERBLE,MARC Payor 125 CROSSBOW LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Activellnactive Bldg Id. 17579.0-125 CROSSBOW LANE Last Billing Date 4/2/2014 3170249 03 Cycle 03 Active UB Services Maint. Account No.3170249 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 64.60 /1 UB Meter Maintenance i Account No.3170249 Serial No Status Location Brand Type Size YTD Cons 34644537 a Active ERT HH b Badger w Water 0.63 0.63 502 Date Reading Code Consumption Posted Date Variance 3/12/2014 514 aActual 17 4/11/2014 -21% 12/10/2013 497 aActual 21 1/17/2014 -18% 9/11/2013 476 a Actual 26 10/15/2013 8% 6/12/2013 450 a Actual 24 7/24/2013 -3% 3/13/2013 426 aActual 25 4/22/2013 1% 12/11/2012 401 aActual 24 1/9/2013 1% 9/13/2012 377 a Actual 25 10/15/2012 10% 6/11/2012 352 a Actual 22 7/16/2012 -2% 3/12/2012 330 a Actual 22 4/14/2012 12% 12/14/2011 308 a Actual 20 1/17/2012 -10% 9/14/2011 288 a Actual 24 10/13/2011 19% 6/8/2011 264 a Actual 19 7/20/2011 -8% 3/8/2011 245 a Actual 20 4/13/2011 -4% 12/9/2010 225 aActual 21 1/12/2011 -21% 9/10/2010 204 a Actual 28 10/15/2010 -6% 6/7/2010 176 a Actual 28 7/15/2010 -6% j 3/10/2010 148 a Actual 30 4/14/2010 5% 12/10/2009 118 a Actual 29 1/12/2010 -4% 9/10/2009 89 a Actual 31 10/15/2009 40% 6/9/2009 58 a Actual 21 7/20/2009 -10% 3/13/2009 37 a Actual 25 4/29/2009 -5% 12/9/2008 12 a Actual 12 1/20/2009 -100% 10/27/2008 0 n New Meter 0 1/20/2009 -100% 10/27/2008 3353 r Replacement 6 1/20/2009 -59% 9/10/2008 3347 m Manual estimate 30 10/10/2008 33% 6/5/2008 3317 a Actual 20 7/16/2008 435% 3/11/2008 3297 a Actual 4 4/11/2008 -87% 12/10/2007 3293 m Manual estimate 32 1/22/2008 -18% 9/5/2007 3261 m Manual estimate 32 10/12/2007 20% i i i i I 6796 Town of North Andover HEALTH DEPARTMENT CHU CHECK#: U DATE: LOCATION: 91 H I- ' - . t H/O NAME: CONTRACTOR NAME: FA-)Cu 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 $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ Title 5 Report ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer r r� 679, 6 - of.Nor+rq�y a Town of North Andover s HEALTH DEPARTMENT C14U CHECK' I DATE: 57 LOCATION: fff--,b(n,—7A ) H/O NAME: 1-0 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 t' ❑ Offal(Septic)Hauler $ 9 ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ; ❑ Tobacco ' $ ❑ Trash/Solid 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 $ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials a White-Applicant Yellow-Health Pink-Treasurer . INVOICE UC. 78 North Broadway Salem,NH 03079 Phone 603-898-9339 Toll Free&Fax(800) 541-9379 March 19, 2014 Marc Kurble Phone: 978-873-0785 125 Crossbow Lane N. Andover, MA 01845 Email: Marc04l@aol.com Pump out existing Septic Tank 150OX $ 260.00 High pressure jet leach lines $ 450.00 Recondition existing"D"box with Hydraulic cement $ 300.00 Also add flow equalizers Straighten vent pipe; move away from tree $ 150.00 Install one new filter in tank $ 175.00 Total $ 1,335.00 i Payment due upon receipt. Thank you, Homeowner Signature John Soucy INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO A. Bottom of Bed 1. Excavation to proper depth 2. With trenches,sides of exca at' are beneath B horizon 3. Edge of excavation 1 e distance from foundation,etc. Comments: B. Retaining Wall 1. Wall height and width specified 2. Waterproofed 3. Wall minimum 0'to leaching facili 4. Wall m specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" _ 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.0 r 1/8"per foo minimum 6. Pipe properly set compact firm b e 7. Pipe laid on c inuous grade in s aight line 8. Cleanouts p ede all change in al gnm and grade 9. Manhol at any 90°change 10. 10'm' mum offset to waterline Comments: D. Septic Tank 1. Level ` 2. 1,500 gal minimum 3. Gas baffle present on outlet �� 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20"manholes 7. Inlet tee minimum 12"under invert 8. Outlet tee minimum 14"under invert 9. Outlet line cemented t/ 10. Air space 3"above tees c/ 11. 2"-3"drop from inlet to outlet 12. Pipe set 13. Compact base with 6"of 1/4"crushed stone under tank 14. Tank is watertight Comments: �%� ve Yes NO E. Pump Chamber I. If separate from tank,compact base with 6"of/4"stone underneath 2. Minimum 2"pipe to d-box if system 3. 20"access manhole 4. Tank level 5. Watertight 6. Tank size a ees with plan speci tion 7. Manhol o grade 8. Chec valve and bleeder hole esent 9. Al in building on separate ircuit 10. A arm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box 1. D-box level 2. Minimum 0.IT'(2")drop from inlet to outlet 3. Minimum 6"sump b 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement c� 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double-washed-'/4"- 1 ''/z" A-- -pea stone Bucket test done? -F"44--'o 2. Minimum 2".of pea stone above distribution lines e� 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5'from edge of property; if not,then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 1 3. Width of trenches agr with plan-Minimum 2',maximum- 4. Vent present if< feet o pecified 5. Distance be n trenches inimum 4' maximum of 6' 6. Minimum stance between enches 1 ' 7. Pipc slop minimum 0.005 o 6"p 00' 8. Depth trenches below outle ' ert minimum of 6". A, Yes NO 9. Pipes set op-stable' ase. Comments: .� I. Leach Field 1. Maximum length of field 100' ' 2. Pipe slope minimum 0.005 or 6"per 100' c/ 3. Separation between pipe 6'maximum 4. Pipes connected at end 5. Separation between adjacent fields 10'minimum 6. Pipes set on stable base 7. Maximum 4'separation from edge of field to first line 8. Minimum two distribution lines ✓ 9. Maximum perc rate 20 mpi �--�— Comments: 715010 ( I Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete _ 3. Sidewall een 12"and 48' wide 4. Acc manholes on each pit 5. Pies cemented with hydraul cement Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond i I Town of North Andover, Massachusetts Form"o.3 f NORTH BOARD OF HEALTH f DISPOSAL WORKS CONSTRUCTION PERMIT SSACHUSE ' Applicant ?/Y�..� •'' L''r• / �`— .���.� AME / / ADDRESS .� TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair (tf-an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CH-Al RMAN,BOARD OF HEACTH Fee �� D.W.C. No. INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at relative to the application of r -� dated^!S-- =9 �_for plans byand dated ��-1�� � with revisions dated-5--t-1w, 1 S—ao-106) I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. UArsh ,,dLicensoseptic Installer Date: Disp al Works onstruc n Permit# BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 6� —a CURRENT INSTALLER'S LICENSE# LOCATION: L LICENSED INSTAL R: off d 4 c SIGNATURE: ELEPHON) CHECK ONE: REPAIR: I NEW CONSTRUCTION: IF NEW CONSTUCTION,PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use OnlyF, BOAPD OF VEAL:!H Fee � $75.00 F Attached? Yes No Z � MAY 2 2001 Foundation As-Built? Yes No f Floor Plans? Yes No Approval /� _ Date: of Now a A Town Of North Andover _ �� d�:�_ ••'° o� William J. Scott Community Development & Services 27 Charles Street Director •� "' North Andover, Massachusetts 01845 (978)68879531 �SSAC1iUgEt Fax 978-688-9542 Jul 20 2000 Board of y Appeals (978) 688-9541 Building Joseph Serwatka Department 31 Kendrick Street (978) 688-9545 Lawrence, MA 01841 Conservation Department (978)688-9530 Dear Joseph: Health A letter was sent to you regarding 125 Crossbow Lane,No. Andover, MA from Department Sandra Starr. The owners have called asking this office about any news on their (978)688-9540 property. This is just a reminder of the letter that was sent to you. Public Health If you have any questions,please feel free to call the office. Nurse (978)688-9543 Sincerely, Planning Department (978)688-9535 Susan Contarino Health Administrative Assistant Of NORTH Town Of North Andover 0 p Community Development & Services William J. scott 27 Charles Street Director " � p;,;.�•'y' North Andover, Massachusetts 01 845 (978) 688-9537 ,SSACHUSES Fax 978-688-9542 Board of April 18, 2000 Appeals (978) 688-9541 Joseph Serwatka 31 Kendrick St Building Lawrence, MA 01841 Department (978) 688-9545 Re: 125 Crossbow Lane, N. Andover Conservation Dear Mr. Serwatka: Department (978) 688-9530 I have received the revised plans for the above-noted site dated 3-17-00, however, information is still missing from the plans. Specifically: Health ♦ There is no information about the elevation of the percolation test. 978) 688-9 * The name of the Board of Health representative who observed the percolation (978) 688-9540 test is still missing. Public Health * The date the percolation test was done is missing. Nurse ♦ The plans are not stamped. (978) 688-9543 In addition, you reference the variance granted by the North Andover Board of Planning Health on May 28, 1998 which was to allow a sieve analysis to determine the Department loading rate of the system since a percolation test could not be performed. There (978) 688-9535 is, however, no reference that this variance was approved by the State DEP as is necessary according to Title 5. Therefore, any variance disallowing a perc test, given by the local Board is not valid. The DEP must always rule on this type of variance. Please address these issues and return revised plans to the office as soon as possible. Thank you. Sincerely, Sandra Starr, R.S., C.H.Q. Health Director Cc: Marc Kerble W. Scott File i Town of North Andover, Massachusetts Form No.2 &ORTN BOARD OF HEALTH 19-2 � w A DESIGN APPROVAL FOR ass"C"„SE�s' SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test Test No. Site Location_ /a t"-'--toss �r�✓ �a�-•moo Reference Plans and Specs. ,Z c <�-a- ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. /d/� Town of North Andover 40RTN OFFICE OF 3?o�"'. COMMUNITY DEVELOPMENT AND SERVICES p 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT 9SSncHus�t Director (978)688-9531 Fax(978)688-9542 March 10, 2000 Joseph Serwatka 31 Kendrick St. Lawrence, MA 01841 Re: 125 Crossbow Lane,No. Andover Dear Mr. Serwatka: It has come to my attention that the proposed plans for the repair of the septic system at the above location have not been updated since a percolation test was successfully performed on October 1, 1998. Consequently the plans have not been approved and the homeowner wishes to proceed with the repair of the system. Please locate the percolation test on the site plans, add the date of the test and information about the inspectors for both the dee hole tests and the percolation test and submit the plans to P P the Health Department for final approval. Thank you for your prompt attention to this matter. Sincerely, Sandra Starr, R.S., C.H.O. Health Director Cc: Marc Kerble File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 0 �j Bbl _� C� 7 O 3 e L 19 Tla= # APPLICATION FOR SITE TESTING/INSPECTION 9SSACHUS�� Applicant 94 NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee 7-!5-i Test No. a 6. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andoyvera Ul•assae#usetts Form No. 1 NORTH .y,,.f.,- �PBOARD OF HEALTH 6g1O 19 46 OL - 0 b! " APPLICATION FOR SITE TESTING/INSPECTION A�R4TEo PPP\'�y �SSACHUSE� Applicant NAME ADDRESS TELEPHONE Site Location - — Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. #Z7 O .ORTk BOARD OF HEALTH ° a • a o a SSACHUSE 30 SCHOOL STREET TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: LOCATION OF SOIL TESTS: Assessor's map & parcel number: OWNER: �v �C{ nP�'I��C / TEL. NO.: ���( 7 y ADDRESS: (ros S/.�., h) f10 A Yldnr M R U>7yS_� ENGINEER: "J—Uek± So TEL. NO.: CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of$175.00 per lot for new construction. This covers them o deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. MpRT1y _, 41 a - n BOARD OF HEALTH ,SSACHUSEt 30 SCHOOL STREET TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: �P - LOCATION OF SOIL TESTS: 125 Cr�O55 Bove Assessor's map & parcel number: OWNER: YEA" TEL. NO.: ` o I ADDRESS: 17_5 L'--OSS 126 rij ENGINEER: -J'- TEL. NO.: CERTIFIED SOIL EVALUATOR: jYG Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) . `—�-- -Ta --V C-_ r 0 o'wl 1'7_'F o 05.N� o f.V Au C-l_ Plot plan #'795. Do 3. Fee of$175.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal are a 75. per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than V-1 shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. P 107 Forest St. FORM 4- SYSTEM PUAZPLNG RECORD . Middleton,MA 01949 (508) 774-2772 Commonwealth of Massachusetts `. AL .A v doje r , Massachusetts 1, System 1°um�ing Record 5 stem I wner 1\e bSystem ocation +) Sol,Sv Date of Pumping: Quantit Pu SWji } Pumped: gallons P L----, i Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes cvccc �� a System Pumped by: License #: .: .Y Contents transferred to: ,. ` IF . Date C� . Inspector 4e0yz=je A y. w THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • :� : 1�. 1 SEPTIC PLAN SUBMITTALS LOCATION: / ��55 &2 c/ NEW PLANS: YES $60.00/Plan REVISED PLANS: S 25.00/Plan w D ATE: - `�— DESIGN ENGINEER: �— _ s��?; I When the submission is all in place, route to the Health Secretary I' Town of North Andover N0RT1y 1 OFFICE OFo °" 't. �°•, o COMMUNITY DEVELOPMENT AND SERVICES 0 1. A 41 30 School Street ` ; WII LIAM J. SCOTT North Andover,Massachusetts 01845 �9 sncHus���y Director May 29, 1998 Mr. Joseph Serwatka 31 Kendrick Street Lawrence, MA 01841 Re: 125 Crossbow Lane Dear Mr. Serwatka: This letter is a confirmation that on May 28, 1998, the North Andover Board of Health granted a variance to 310 CMR 104 to allow no perc tests to be done at the location mentioned above. Please call the Board of Health Office if you have any questions. i Sincerely, Sandra Starr, R.S. Health Administrator S S/cjp cc: DEP Wm. Scott, Director, P & CD Marc Kerble BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Address /25- c.Qoss w /,,o , 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 Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department Gy r10RT1N Town Of North Andover O Tao ° y Fa'.•.�." h �°�0;, Community Development & Services William J. Scott 27 Charles Street Director North Andover, Massachusetts 01845 (978)688-9531 { 1 SSACHUS� Fax 978-688-9542 a J Board of Appeals August 15, 2000 (978)688-9541 Building Joseph Serwatka Department 31 Kendrick Street (978)688-9545 Lawrence, MA 01841 Conservation Department Re: 125 Crossbow Lane (978)688-9530 Health Dear Joseph: Department (978)688-9540 This is to inform you that the revised septic system plans dated 05/22/00 for the site referenced above has been approved for repair. Public Health Nurse3 (978)688-9543 If you have any questions,please do not hesitate to call the Board of Health ' Office at 978-688-9540. Planning Department Sincerely, (978)688-9535 z Sandra Starr,R.S.,.C.H.O. Health Director > y SS/smc i a cc: Kerble File r DATA,. LOCATION: — LEN GINEE= B \1r 0. , ��I i_N��._� S. PEF.00LATION TEST 00 i ONl DEPTr OF PLRC TEST: a TIME OF SG^K: inures Icrc) � r TIME A.T '12" � y TIME AT 9" 1/0 TIN1E AT E GVE=NIGFT SOAK TIME ST,=.F,TED Nr iD, ,v e2,5i ,ink es) T INIE T IME ,^, 7�FT] — - I r -_j J_LT, 4. -1-- j i i C x . ' �( r ,tc _f %+w.v5+++•�.�`v�3r...�:•R�>k€tr+#,'�,o z'.:1�`,%..d�vd.� �"s DATE: _ _ _(_z5 LOCATION: c� .6 S (3 0U-1 ENGINEER: 1c�_1 �/,z�/�. . _ BOH WITNESS.- PERCOLATION ITNESS:PERCOLATION TEST# _` BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: _ _ (At least 15 minutes long) TIME AT 12" TIME AT 9" TIME AT 6" � V9 OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: (At least 15 minutes) TIME AT 12" TIME AT 9" TIME AT 6° SGI �s �s MEN OF -• EE PLAT 105 N' 47,Su sl. 44•,SSt 4 f9. w It'? 1 tb a' ANA SCC O v C ,t. � t t ANE o ao +' eAo`s a,n 477.tu 4tje �sy tt m � w e w Z tit• Lt � V .r t i i 6 ID ) 11 ,yf2!4(. ` p ft ,•A i AS y• 7 I ?o S W7 wa goo ItG itsItt : Da A7 46 4> > Is O �4� 4v 41a7ae Cb 04 v 0 b t4 tv • 04 f Lao CO t � 41191 ►' S� its f'A 14 s• I M e� . 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I m �.► , a q,.5 AA b� MSb ty ♦� k. ,a'3�` - LIB 1k l I IGI I L� W 9 . 1.,XW Aa 1 3GG6 Ac. ,o► 6 s PSE ,4� ,_ 3s ro 1 &boe` ,ZZAL I.oM 4, � za7a-Ac. tiN E z.31a�• IG3 IG4' Ips ��+ r Lot A. 43 679 tpl Ac. s � G7 ,?`A`•" >° 35 Z3 Ac- 5` 8 �7 j Lw r��' 37 2 lfol 5 i 52 tos �y ~ I 2s9 6.st�i�'/ ` 4' G qti I 80 tc v ." 2.59�• f 1 °,Ar. Let A.. Ip Sat Nerd. C 1 3 . IaI A� 1•°I'^° � cs t ti"` y6 -�T �.acaA 40 7,4•x. s.et As 10 ZA Ae. i 3 1.28AC 1.03AC 1.8 O 28 210 2.087 320 239L2 240 L22 d' toi.A b ss /� 237 s as C 75AAf~ L19 E. DO 695 1 AC. � � \.,5'` LC A, OOK 230 L 3 t.02 A- 35 .13 AC. 17 1.75 AC. 4 e°r' LOAC 1.47 AC. 230 L4 gq� `9`'i '" 73 tnl L02AC..10 L14 L13 L 12 1."22A'C. L 223 2245 �r a 32 231 5 r o Aa. A 229 234 L 15 L!! L6 r -JA, %.0 7G L 1 Al�•rd. � �r ti I2.519 .23 AC f•0 AC. 1L 226 All Cpl' ' yp■" 228 L7 1 0 227 L9 Q e 18.2 Ac. `Y ' � � � Ie.2Ac• '.1�� SEE PLAT 106 D ,p y"h r�7 o ah L �a ¢ IV C o ZI5 + oaoh�' all -� p f a- 'c Ar MA Elf tyl r-6 r 1 r J �5w7W jTm '"-�� _._ ".s 719 �'�rte+g....� N�j'��-.J • �i,� y �d-�-�����1-1 __ ____ �, ,� Ir �, �� i i 1 �` ., / ((( i I t E i t IE A I y ALL- III 1 Y 1(_000 Qlr- +` Lj -0 — TH p� rJx2c1 I SCALE: �/ APPROVED BY: DRAWN BY DATE: REVISEn DRAWING NUMBER 1 FORM U TOWN OF NORTH ANDOVER + i LOT RELEASE FUIUI SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) . PERMANENT ADDRESS (ASSIGNED BY. D.P.W. I,S"TREET r,xld�'PLICANT 114 k4 fAP, 9 r PHONE 69/- ll qV I'PA E OF APPLICATION 2- 10 TOWN USE BELOW THIS LINE ' PLANNING BOARD DATE APPROVED ' TOWN PLANNER DATE REJECTED ONSERVATION . COTTHISSION DATE APPROVED CONSER ATION AD IDATE REJECTED ARD OF HEALTH DA'T'E APPROVED THE H DATE REJECTED DEPARTrIENT OF PUBLIC FJORKS DRIVEWAY PERMIT SEWER/(DATER CONNECTIONS �RE DEPT. v,t —' / /g� RECEIVED BY BUILDING INSPECTION DATE rti ( agents tlie'Plaand health boards,nnin This form shall be signed by the age g g the Conservation Commission prior to the .issuance of any building permits ', for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. . TO: NORTH ANDOVER, MASS $ &PT o-9 19 83 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at Zo 7` It CRGSSS bow Ll4/yE North Andover, Mass. SITE LOCATION The grades and construction are as specified in iM plans and specifications dated X-7 19 3 . .6y NE vE ASS-(? A:7�A�i 0 I eer }Ze nitarian S113S�N�a�� A16 7-,C A5 S u i L,,v- 101-A,U Board of Health BKPTIC STSTEM North An ver Haas. /� �fS�5�3©c.J INSTALLATICK CHSRB LIST LOT (7VID DATE Il(I PHUTF� EXCAVATICH 0 FAIL APPRReaffonst FAIL OK 1. Distance Tos a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PVC Pipe 4. Septic Tank a. _Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank — On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flox 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clem Double Washed Stone 7. Leach Pits a. Dimensions b. Stone D c. Spla ads d. Tee e. t Pipe to Pit - Both Sides. f Clean Double Washed Stone 8. No Garbage Disposal 9. yinal Grading Inspection 10. Barricading Covered System As Built Submitted /7. a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations 10 e: Water Table P. Board of Health - Nar;..k: ,*ndover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST -LOT AMMED DATE DISAPPROVED DATE Provided: Reasons: A4 SLE �lnv�n Title V FAIL CK Reg 2.5 The submitted plan must show as a ndmiz *- the lot to be served-area,dimensions lot #,abutters location and log deep observation hoes-distance to ties location and results percolation tests-distance to ties design calculations & calculations showing required leaching area ( location and dimensions of system-including reserve area f) existing and proposed contours g) location any vet areas within 7()0' of setirage disposal system or disclaimer-check wetlands napping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 1DO' of sessge disposal system or disclaimer-Planning Board files 3) knoka sources of -.ester supply within 200' of stege disposal a _ system or disclaimer location-of any proRo_&ed-veil to serve lot-100' from leaching facili location of kater lines on prmporty-20' from leaching faei3ity location of benchmark (n drive-ways garbage disposals no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tangy:, distribution box inlets and outlets, distribution field piping and Other elevations } mayj aim ground inter elevation in area se-►.age disposal system s) plan mast be prepared by a Professional ID�ineer or other professional authorized by law to prepare such plans Reg 6 SeDtic Tanks a) capacit. es-150% of flow, vater table, tees, depth of tees, access, pumping b) cleanout el c) I.0' from cellar imll or inground s- .-ng pool (d) 25' from subsurface drains Reg 10.2 Distribution Foxes a) slope greater than 0.08 Reg 10.4 ( b} mop ij14M j toe �' Ito C.eaM'l'C�uIG-5• I� Subsurface Design Check List Page 2 ` FAIL OK Leaching Pits .. . Leaching pits are preferred where the installation is possible leg 11.2 a) calculations of leac ea-rd ni 500 sq ft 11.4 b) spacing 11.10 c) surface % il.11 d) cover mate e) 1-1x2Ix4n lash pad f) tee elbow g) no bends in pipe from d-box to pipe Leaching Fields teg 15.1te" , no greater than20 ninutes/inch moi area- m= 900 sq ft 15.4 construction of field 15.8 surface drainage 2 % 3.7 201 from cellar va11 or inground swimming pool Leaching Trenches�- .eg 14.1 a) calculattons o eaching area-min 500 sq ft 14.3 b) spacing-4 min 6 ft with reserve between 14.4 c) dimRe s 14.6 d) coaction 14.7 e) 114.10 f) surface drainage 2% Dowa i 11 Slo e a slope y x = to be s_`iovni b) y/x x 150 = (to be shown) _ Pun s eg 9.1 a) approval 9.6 b) stand-by power SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No G,�o� S as cJ Lot No LQc/Subdiv. --z7xlS 4//,s = Pland Owner A:Ae A ^a5 5;'0'090 Investigator T 1349mG194t Ci.*//a' (404�aU?)bserver : SOIL PROFILE DATES 1. lev 2.Elev 3.Elev_�� " �+:--E1ev 771p. -Z. 0 0 q zo l3'J 0 /2v�830 l 1 Tey 1 Tts 1 Ties tq Teat Pit's 2 2 2 Q 2 3 3 3 �p 3 4 4 I�R.A.t E` N 4 4t2-b.)G' 4 7 Q) 5 5 5 5 � 3 6 6 6 6 Z� `7 7 r `, 7 u s.y 7 8 8 8 8 ,,j�,S 9 9 9 9 10 10 10 10 it Benchmark Location Elevation Datum PERCO;ATION TESTS DATES '71,q 7, $ /�-o 1: i/ 83 Pit Number 1 2 3 �+ Start Saturation Soak-Minutes start e sZ �ts � Drop of 3"-Time Drop of 6"-Time M6ns.lst 3" drop Z Ylin s.2nd " Drop /S / e P6;er Percolation 5 s i 3. 3A k bA ,�.r�a As 001, 4t I f�• 'S'� 2 �05EPN `���' f f o �Fcz; FESSi 0 NAL SP -_ ,e i 1 i i <,v � � i FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 No. - Date: _ 8 Commonwealth of Massachusetts �o ANDo vek , Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By: jC�tv1►t'f t�,Q. Date: 4 --7—'F,6 Witnessed By: w o5,4 ti/ I r—U_121-0 _... Locacan Addrus a I Z („���j Cj 6349W L_Aj 0—r'r Na . &1-4 //L.E Ae ,a kphorejZ ��OSS X16`V L/� Tepinrc! l�lo. AN p0V E--R-r Newconstruction ❑ Repair _ Office Review Published Soil Survey Available: No ❑ Yes Pd Year Published l R Publication Scale td Soil Map Unit ADrainage Class A ....... .. Soil Limitations Surficial Geologic Report Available: No ❑ Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) ........................................................................................................................ Landform ............... Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes i Within hin 500ear flood bound No ❑Yes ElY �' Within 100 year flood boundary No Dyes ❑ Wetland Area: National Wetland Inventory Map (map unit) ....................................................................._................. - Wetlands Conservancy Program Map (map unit) ........................................................................... ...... ........._ Current Water Resource Conditions (USGS): Month Range :Above Normal F/ Normal ❑Below Normal ❑ Other References Reviewed: DFP APPRO VFX FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. Z� L N , Ort-site Review Deep Hole Number Date: Time: 9 A .0 , Weather 'Jrb ' Sv�v1Vy Location (identify on site plan) Land Use j_AW ilJ Slope M _ `� Surface Stones Vegetation 6x-e't'S'S — — Landform O c�-r t,--t--5 t4 Position on landscape (sketch on the back) Distances from: Open Water Body -100 feet Drainage way 7/d d feet Possible Wet Area -7I pd feet Property Line 50- -t feet Drinking Water Well 7160 feet Other DEEP OBSERVATION HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA► (Munself) Mottling .Structure,Stones,Boulders, Consistency, % Gravel) O—lZO M P Dvrw p Parent Material (geologic) OepUuoBedrock: Depth to Groundwater: Standing Water in the Hole: 4y+ Weeping from fit Face: Estimated Seasonal High Ground Water: DFP APPROVED FORM- t2107r95 c 1 FOR_'%1 11 - SOIL EVALUATOR FORM Wage 2 of 3 Location Address or Lot No. lZrj ,��cf �loGc_l , Oil-site Review Deep Hole Number 7-Z Date: 4-1x'98 Time: Y444 • Weathera �o 4 v 4ou ry y Location (identify on site plan) Land Use L A-W 0 Slope (%) Surface Stones_— ' Vegetation rj - Landform Position on landscape (sketch on the back) Distances from: Open Water Body >--10o feet Drainage way 7 100 feet Possible Wet Area '7106 feet Property Line 76 t feet Drinking Water Well y/o p feet Other - DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling .Structure,Stones,Boulders, Consistency, % —Gravel) C. S,tNp _ OLS 1--S L I I MINIMUM Of-2 HOLES RF_GDT��� POSED DISPOSAL AKtJ, Parent Material(geologic) - d t�T 4.J A -5j ,ocl DeptMo8edrock: Depth to Groundwater: Standing Water in the Hole: 7 Z Weeping from Pit Face: .i Estimated Seasonal High Ground Water. l ' DEP APPROVED FORM- 12/07/95 s FOR—%I 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. Opt-site Review Deep Hole Number Da1e: 4--/—f8 Time: 9 A,M , WeatherS U�,�y Location (identify on site plan) Land Use LA ex Slope (%) 57--Surface Stones — Vegetation .5 Landform �V.T-AAS 4. Pt. eN Position on landscape (sketch on the back) , Distances from: Open Water Body '7-10d feet Drainage way > 10 0 feet Possible Wet Area ;;P/00 feet Property Line GQ-* feet Drinking Water Wet[ ])Op feet Other - DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon ]O(USDAI il Texture Soil Color Soil Other surface(inches) (Munsell) Mottling .Structure.Stones.Boulders.Consistency. % Gravel Yle r7v Y4#1 10 � — - G,eAu� Y �6 9. C. �012 A-40 II MINI Parent Material(geologic) e V-r A-).-S k1 Oepthto8odrock: 7 124 Depth to Groundwater: Standing Water in the Hole: N Weeping from Pit Face: 8 e/ Estimated Seasonal High Ground Water: 'Z DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Determination for Seasonal High Water Table Method Used: - ® Depth observed standing in observation hole.. inches ❑ Depth weeping from side of observation hole inches ❑ Depth to soil mottles inches i X Ground water adjustment- _.._ ..__.. feet- • 41.3 PSR f4e,4LTt-4 "T Index Well Number .. Reading Date ....._:. Index well level ... .. Adjustment factor Adjusted ground water level j Depth of Naturally Occurring Pervious Material_ Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? yC—S If not, what is the depth of naturally occurring pervious material? Certification I certify that on ' (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date 4- /3i-�� i DEP APPROVED FOP-%I-12/07/95 FORM 12 - PERCOLATION TEST Location Address or Lot No. /2 �g5 P22&1 L" COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test` ---- Date: 4---7 Time: �o ,4 , 04 • Observation Hole # T_ 3 1_T_2 Depth of`Perc Start Pre-soak End Pre-s-oak Time at 12" - - Time at 9" Time at 6" Time (9"-6") Rate Min./Inch - L2 gY C', rvS. Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed Site Failed ❑ .............................................................................. ...................................................- Performed By: �`o �i;e-W.4:7X Witnessed By: — Comments: Z7 .:.....:. .fir. _`? .... ,.q >s3o.✓> �. . DEP APPROVED FORM-12/07/95 i j i i V/�; 62;4