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Home My WebLink AboutMiscellaneous - 125 SAW MILL ROAD 4/30/2018 (2) 125 SAW MILL ROAD _ 210/104.6-0105-0000.0 - D i i X .,,. ti ` � cr'C•vp tz �'!y � + .r+/ a +rm�la iii• t p 1 N r a c .;•. 9 �x+Lggrl�y Y ��1 Y ra "1 y j`ai r rr � r ..r MAP # 47 Fj •" ;'''(•;1i°`' � LOT # r : { - �� # PARCEL . . •._ STREET . � �ONSTRUCTIO.N—APPRO ._.__ HAS PLAN REVIEW FEE .BEEN PAID? YES NO V PLAN APPROVAL= DATE 3l Pp_ Y —,L<)�Q DESIGNER: �U I'>�ES/UCS PLAN DATE. CONDITIONS WATER SUPPLY: � WN WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DALE APPROVED BACTERIA I DAIE flPPRUVED BACTERIA II DATE APPROVEll COMMENTS: FORM U APPROVAL: F'PRO L TO ISSUE YES NO DATE ISSUED / BY CONDITIONSs FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: ;_Ya�`;_<<:::. ' •; - EpT��_�SY�.Z�M�.NSSflt� ,..UQ +x +.4 S THE* INSTALLER LICENSED? :': +^ �� - S NO ` .TYPE OF, CONSTRUCTION: ? NEW REPAIR ..-- NEW CONSTRUCTION: CERTIFIED PLOT -PLAN REVIEW YES NO CONDITIONS OF..APPROVAL YES NO { 4 " (FROM FORM U) ,ISSUANCE OF DWC PERMIT . NO DWC 'PERMIT N0. INSTALLER: I�tJD .C7� G� BEGIN INSPECTION AYEBLAO. EXCAVATION INSPECTION: ; NEEDED: ti PASSED .. :,: w,= �q BY < ;CONSTRUCTION INSPECTIONS NEEDEDt S BUILT PLAN SATISFACTt 9Y.. , YES APPROVAL TO BACKFILL: DATE: ( BY .FINAL . GRADING APPROVAL: DATE BY DATE. 9�� BY FINAL CONSTRUCTION APPROVAL. i Residential Property Record Card Parcel ID: 210/104.6-0105-0000.0 MAP: 104.6 BLOCK: 0105 LOT: 0000.0 Parcel Address: 125 SAW MILL ROAD FY; 2017 PARCEL INFORMATION Use-Code: 101 Sale Price: 360,000 Book: 04476 Road Type: T Inspect Date: 05/29/2008 Owner: Tax Class: T Sale Date: 04/10/1996 Page: 0114 Rd Condition: P Meas Date: 05/29/2008 SILVA,EDWARD H Tot Fin Area: 3714 Sale Type: P Cert/Doc: Traffic: M Entrance: C Address: Tot Land Area: 1.010 Sale Valid: Y Water: Collect Id: RRC 125 SAW MILL ROAD Sewer: Grantor: BUSCI,JOHN Sewer: Inspect Reas: C NORTH ANDOVER MA 01845 Exempt-B/L% 0/0 Resid-B/L% 100/100 Comm-B/L% 0/0 Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 10 Main Fn Area: 2558 Attic: N NBHD CODE: 7 NBHD CLASS: 7 ZONE: R1 Story Height: 2.00 Bedrooms: 5 Up Fn Area: 1156 Bsmt Area: 2362 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: H Full Baths: 3 Add Fn Area: Fn Bsmt Area: 144 1 P 101 S 43560 1.000 N 224,334 Ext Wall: F6 Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0.010 N 76 Masonry Trim: 87 Ext Bath Fix: Tot Fin Area: Foundation: CN VALUATION INFORMATION Bath Qual: T RCNLD: 464009 Kitch Qual: T Eff Yr Built: 1980 Current Total: 688,400 Bldg: 464,000 Land: 224,400 MktLnd: 224,400 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1981 Prior Total: 649,500 Bldg: 422,900 Land: 226,600 MktLnd: 226,600 Sound Value: Fuel Type: O Grade: GV Cost Bldg: 464,000 Fireplace: 2 Bsmt Gar Cap: 2 Condition: A Att Str Val 11: Central AC: Y Bsmt Gar SF: Pct Complete: Att Str Va12: Att Gar SF: %Good P/F/E/R: /100/100/80 Porch Type Porch Area Porch Grade Factor P 18 W 140 Sketch Photo 10 14 W FM 1440 qlF 6 �t 28 1224 Sq-Ft 2t3 1138 Sq.Ft 28 : l _Ft - "'lr- 125 SAWMILL ROAD Commonwealth of Massachusetts RECEIVE® Title 5 Official Inspection Form OCT 22017 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NORTH ANDOVER 125 Saw Mill Road HEALTH DEPARTMENT Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9/20/2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not beal er in any way. Please see completeness checklist at the end of the form. Asti Important:When filling out forms A. General Information (r--Nf\ on the computer, use only the tab 1. Inspector: O �(L key to move your cursor-do not Neil James Bateson use the return Name of Inspector key. Bateson Enterprises Inc. r� Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 SI-15 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 my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-20-2017 InspUftnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 125 Saw mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-20-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., pump septic tank, install new outlet tee, new outlet pipe to d-box, new d-box &riser, inspection from B.O. H. , septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 � S�TTL'ED6yc • G� PUBLIC HEALTH DEPARTMENT ^' �Q Town of North Andover 0 Community and Economic Development Division D CERTIFICATE OF COMPLIANCE As of: September 20, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box & Outlet Tee Repair of On-Site Sewage Disposal System By: Todd Bateson — Bateson Enterprises, Inc. At: 125 Sawmill Road Map 104.B Lot 0105 North Andover, MA 01845 The I ce of thi cat- s 11 not be construed as a guarantee that the system will function satisfactorily. Br' n J. Grasse, CEHT Director of Public Health 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov oi, Commonwealth of Massachusetts Map-Block-Lot 104.B0105 BOARD OF HEALTH -- Permit No------------ • � Permit North Andover BHP-2017-0548 PA. FEE F.I. $175.000----------------- �� DISPOSAL WORKS CONSTRUCTION PERMIT i;Ga'�" Permission is hereby granted Bateson Ent _ _ -------------------------------------------------------------------------------(�`,, to(Construct)an Individual Sewage Disposal System. V DL j,b at No -- - 125 SAMILL ROAD ---------------W----------- ---------------------------------------------------------------------------------------------------------------------- - as shown on the application for Disposal Works Construction Permit No. 13HP-2017-054,,o0 7ated Sep b , 017 ---------------- - -------- ------------ - --- ------- Issued On: Sep-12-2017 BOA OF HEALTH x: ADD.rication for 90c Disposal System TODAY'S DATA Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 $2sa 00—Full Repair $,125.00-Component Aimlication Isherebymade for a oennit to: Construct a new on-Rite sewage disposal system* ❑Repair or replace an existing.on-site sewage disposal'systein* M4eepair or..replace an existing system component—What? ReA cp. A. Facility Information ©L :+ Jr J1�1w/I?•`/l � Address or Lot# Cityfrown ti0 2.-*TYPE OF SEPTIC SYSTEM*: y SF-QNPN�N'( NoE �ZM ❑ Pump 5joi5ravity(choose one) "T pump system,attach copy of electrical permit to application`** �0�� 0 Conventional System (pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ Q Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ❑ Does the system require an effluent filter? Yes No _LZ If yes, does plan specify make and model of filter? YES=(no further info. needed) 'NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the ModcV 2. Owner Information L; wWAt'-� S,-/vt Name Address(if different from above) A- Cityrrown State Zip Code Telephone Number 3. Installer Information Name Name of Comp ar AMON E p ; l/ ;((4 LATER, RASES,INC. Address ANDOVER, A UAD l'''1�•- Gil�'/�, jai 0 Cityrrown, State Zip Code ?7 'KI.5-4"703 Telephone Number(Cel!Phone#if possible please) 4. Desi_gner'1riformatiorr Name Name of Company Address Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit.Page 1 of 2 M riM�y Applica-Von..fo or� r.peptic Dfsp.osal.sn:tern Am. C.- nstructionrM- it TODAY'S QATE ,..,�` OI ' " 1TD C�'V MA :41845 �: so 0o*:U!Repair `°- . . S'(25.00;.Compbn'ent ,.-PAGE 2 OF 2 A. Facility.lnforllnatien continued .... S. Type,of Building Residenual-Dwdlling or Eloommercial B. Agreement The underslgned agrees to-ensure the constructlon and maintenance of the afore•descrlbed on-site sewage disposal system In accordancewlfh the provls/ons of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of worth Andover,and not to place ahe system fn operation until a Certificate of compllancohas been Issued by this Board of Health. -7 Name Date Application Approved By: (Board of Health Representative) Name nate Application Disapproved for the following reasons:" For Office.use on1w. 1 "Fee Attached? Yes _ ` No 2,. PtojcctMadager Obligadon Ford Attached? Yes 3.: Pun?n_5vstem? Ifso Attach cony ofF/��rri� —"Ab- 4., FoundationAs,Builz?(hew constructlon ronl}r); ye . (Same scale$s a PP Y p )ro ed &, No . • A FloorPlans?•(hew ddhstructlon'only): es • No pifcatibn{or.p(sposat Systerll: onstruc{taia t'enntt:Raae 2 rit 2 SEP'. IC sr .� .ofi 'r .� sr '�oBr.�r��r�ts As flit-NqtffiAn&vi=&=scdbuuqa fog tie iatx ift-f -,&6aeptic epetq�fat the;�p�Yat: (Ad4iiu dvge k ) -14ca pLm by Rt h ivt to tha.app8txd**of AM dabd. Dated klo=rs catr,) — ttvidow&ted (Last sed daft) I ut:dctttafid the following obligations for M"2'gement of-*& 1. As the fast Reti'I ai m.obliget+ed io cbtzi Piper and-Board affle�t jvpr �p s �yyp`,etb°s ia8 any.tivosk as a dte..I mt have the; _t+a .o 4�+ �d t � , . 2. ha9se mttnlIer;.I�n LFII nary and i1Wpqdbm XEe ctmattAget,�r aaay athtrparaon not i�arc�seved�mY co�ay�p� oa s�,kbc spate{n!a •feem •ahall.bsw,st�pl�tbI�e. � .. �t�y,then . tia LY G e 9�vc�C :p �a the sppItgtb�e;Jc�s r -UMMNI pow "1I ALVAMA Ban I tnv '• .��` Pdd ' . • a b�;d!aa�;f�t: �it'' �tfii`sgecdo� �ea•not lzave;�b�pr�saut•. .. • .6. PRO '1131, a � OIC -ba 6bi9t6cd•to 1hc.Rcvd-cfHoah�t, t the ef#gueru must ' •• 6epta�t<farr t�,iaap a � � €Qr•aa�gec�.time.'Iiasmltq=sriusr . p•tti A►ork ��:�dectzlattavat�lady wd nhle:m gw� o e .. •—$ts tiIIer tanet e s l! d#n a ieQ plbte: Iasbdia docs not . . have#o bevn�ite.• .•' •• .• . 4. 1ls teiastali= I t a dthatcily titapgtsfoaa he. t'�et�a►t6csr g)f {Mdl irea ' �uo�piete�g�sist:a�Islt�st aPt�e sp�ta;i_�ir##�!bscd�t�'�mai�dtatfaa j, 4 r r• ra t8e�•I t� deratnail •�nmbb�be•e� }h�pct�f tb�� . vc Dura"d wf A'O elm ddis afdrr e '' i� Ias►Pet o�ahbe'wdxadst�10 fe d arsr beep s+eac6cal . c Pra:l�aape��by8o�tat�Ta:hSstrrfforoaa8u . d . (Alai afiGaak,I]- ang ,SA104MWS,PMP fiber,&49W tl oilier comprzam� � . . • 6. i 24,1JO A th et LSM.a,, t+ra;bM110 forte Ift.Oakml t�aII - b Uade:tdat:ued sc.B • Crp ft NORTN 8 0 G6 6O' = p Town of North Andover s^° HEALTH DEPARTMENT sSACMUSt CHECK#: 1556 DATE: /9-iZ-,; I� LOCATION: S H/O NAME: CONTRACTOR NAME: Ar,(Je 5 O n 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 J �0�( $ SEPTIC Systems: ❑ Septic Soil Testing $ ❑ Septic-Design Approval $ x Septic Disposal Works Construction(DWC) $ /75❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ fll)D hwlih Agent Initials White-Applicant Yellow-Health Pink-Treasurer e North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 125 Sawmill Road MAP: 104.13 LOT: 0105 INSTALLER: Todd Bateson — Bateson Ent. DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: b-Box Repair Only- 9/20/2017 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ElExisting septic tank properly abandoned ❑ Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by ^rr� visual testing j�,�/t ❑ Inlet tee installed, centered under access port ' •^. ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: 9/20/2017 Added New Outlet Tee/gas baffle. PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: 9/20/2017 All Set— Brian LaGrasse SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM Gravel-less Chambers ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED Certification❑ o of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib.to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws • North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 125 Sawmill Road MAP: /0Y. /3 LOT: 01055 INSTALLER: Bateson Ent DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: P - 60X G INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ _Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned) Internal plumbing all to one building sewer Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged gallon tank h El 1500 g as been installed H-10 loading N Q'w ❑ Monolithic tank construction `u ❑ Water tightness of tank has been achieved by visual testing ,.S ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base cQ/ H-20 D-Box Inlet tee (if pumped or >0.08'/foot) [✓]� Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) [• Schedule 40 PVC Pipe Comments: 4� (so o� a.A SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN A CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws M 1 Commonwealth of Massachusetts P9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms maKnno� �t��d in any way. Please see completeness checklist at the end of the form. ER11W IvJ Important:When2017 filling out forms A. General Information 5 on the computer, OF NORTH ANDOVER use only the tab 1. Inspector: TO OWN pRTH ANDOVER key to move your HEALTH cursor-do not Neil J. Bateson use the return Name of Inspector key. D Bateson Enterprises Inc. �y Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code • 978-475-4786 SI-15 Q 192 01) Telephone Number License Number pel 044-y'rU, 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 my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority c ` 9-5-2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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.doc•rev.6/16 Title's official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name informationis required wirfor for every North Andover MA 01845 9-5-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Outlet tee &d-box needs to be replaced. Riser needs to be installed on d-box. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins.doc•rev.6116 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 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is every North Andover required for eve MA 01845 9-5-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name required for is every North Andover required for eve MA 01845 9-5-2017 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 l5ins.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is every North Andover required for eve MA 01845 9-5-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 -�� 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 ears usage Yes 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Ci ffown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2016, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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.doc-rev.6/16 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 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank original, d-box&trenches installed 4-5-1996, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.6 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast Iron through wall, 4" PVC in house, no leak visible. Septic Tank(locate on site plan): Depth below grade: 0.6 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' Sludge depth: 3.. t5ins.doc•rev.6/16 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 5•°` 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Outlet tee corroded, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover under porch, unable to excavate cover. 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: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityrrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken, replaced it. D-box level&distribution equal. Evidence of carryover. Evidence of leakage, has corrosion holes. D-box needs to be replaced. D-box 2'deep, needs riser installed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •''r 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 71'long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts v: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 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 . 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01845 9-5-2017 page. Cityfrown 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 UiCn paste Deck I g o A A-voo _ 10ie - ( - vc iL4 a k L4 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •' 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information isequired or every very North Andover MA 01845 9-5-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 3-26-1996 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Saw Mill Road Property Address Edward Silva Owner Owner's Name information is required for every North Andover MA 01$45 9-5-2017 page. city/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Town of North Andover Tax Map # 210-104.6-0105-0000.0 Parcel Id 16427 125 SAW MILL ROAD SILVA, EDWARD H Since Jan 2003 JUDITH A SILVA 125 SAW MILL ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2018 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until SILVA, EDWARD Payor 125 SAW MILL ROAD N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18135.0-125 SAW MILL ROAD Last Billing Date 7/18/2017 3180163 03 Cycle 03 Active UB Services Maint. Account No.3180163 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 268.71 /1 UB Meter Maintenance Account No.3180163 Serial No Status Location Brand Type Size YTD Cons 13242444 a Active 00 METE METE w Water 0.63 0.63 1748 Date Reading Code Consumption Posted Date Variance 6/13/2017 2814 a Actual 55 7/25/2017 70% 3/10/2017 2759 a Actual 30 4/12/2017 -7% 12/12/2016 2729 aActual 33 1/23/2017 -30% 9/13/2016 2696 a Actual 46 10/24/2016 23% 6/17/2016 2650 a Actual 40 8/2/2016 63% 3/15/2016 2610 a Actual 24 4/22/2016 -10% 12/14/2015 2586 aActual 26 1/20/2016 -18% 9/15/2015 2560 a Actual 34 10/16/2015 -27% 6/11/2015 2526 a Actual 41 7/24/2015 91% 3/19/2015 2485 a Actual 24 4/28/2015 0% 12/15/2014 2461 a Actual 23 1/15/2015 -70% 9/16/2014 2438 a Actual 81 10/15/2014 216% 6/12/2014 2357 a Actual 24 7/16/2014 -27% 3/14/2014 2333 aActual 32 4/11/2014 -26% 12/16/2013 2301 a Actual 46 1/17/2014 -36% 9/13/2013 2255 a Actual 70 10/15/2013 89% 6/14/2013 2185 a Actual 35 7/24/2013 -4% 3/20/2013 2150 a Actual 41 4/22/2013 20% 12/13/2012 2109 aActual 30 1/9/2013 -64% 9/19/2012 2079 a Actual 91 10/15/2012 105% 6/18/2012 1988 a Actual 43 7/16/2012 2% 3/20/2012 1945 a Actual 43 4/14/2012 -4% 12/19/2011 1902 a Actual 46 1/17/2012 -28% 9/16/2011 1856 a Actual 65 10/13/2011 26% 6/13/2011 1791 a Actual 49 7/20/2011 -2% 3/15/2011 1742 a Actual 50 4/13/2011 2% 12/15/2010 1692 aActual 43 1/12/2011 -55% 9/27/2010 1649 a Actual 127 10/15/2010 117% NORTIv 0 '1 2 F 9 • Town of North Andover � '• HEALTH DEPARTMENT ,S3 CHU`�t4 CHECK#: �,,Sy3 DATE: - ,.Z -4201-7 LOCATION: 50.w 6 42L H/O NAME: _ Si 1V0_ CONTRACTOR NAME: &-,aan 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) $ V ❑ Title 5 Inspector SS $ �' $ 6-0 " Title 5 Report co P ❑ Other(Indicate) $ He gent Initials White-Applicant Yellow-Health Pink- Treasurer Town of North Andover o E NORTH 1 OFFICE OF 3? << °,6o c COMMUNITY DEVELOPMENT AND SERVICES ° . p 146 Main Street North Andover, Massachusetts 01845 5* SSACHUSE� TOWN OF NORTH ANDOVER BOARD OF HEALTH April 5 , 1996 CERTIFICATE OF COMPLIANCE This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by Todd Bateson installer at 125 Sawmill Road, North Andover, MA has been installed in accordance with the provisions of TITLE 5 of the State Sanitary Code and with Board of Health regulations as described in the Design Approval Permit #810 dated 4/3/06 . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. oard of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover, Massachusetts Form No.3 BOARD OF HEALTH 9 NORTH / 19 L DISPOSAL WORKS CONSTRUCTION PERMIT SSS^CMUSES Applicant TO D �1�TE5aAj NAME ADDRESS TELEPHONE Site Location T Permission is hereby granted to Construct ( ) or Repair ( n Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee J D.W.C. No. �/0 Town of North Andover, Massachusetts Form No.2 f NORTp BOARD OF HEALTH L w 9 DESIGN APPROVAL FOR SSACHU5E4 SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant- Qvr-'A'— � Test No. : Site Location 1 4rL4j)a &L .Q 1 L Reference Plans and Specs. /C ENGINEER DESIGN U 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. g�� ,DATE Y` Z �� Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED APPLICANT Jo�,� �y 6L( ASSESSOR'S MAP ADDRESS PARCEL # LOT # STREET 5P101116 , ENGINEER T��ESitJ� ADDRESS PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED T E 114 55i/v( t k)CH<�F 5 2 TD t5 7-19,7 6- � YsT�� PLAN REVIEW CHECKLIST ADDRESS 03 ENGINEER---F. D VFR E 51j L GENERAL 3 COPIES L--' STAMP LOCUS NORTH ARROW �/ SCALE CONTOURSk- PROFILE &, SECTIONy BENCHMARK SOIL & PERCS J.. ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?-)I DRIVEWAYy(Elev) WATER LINE FDN DRAIN SCH40 ✓ TESTS CURRENT? SOIL EVAL SEPTIC TANK MIN 1500G . 17 INVERT DROP GARB. GRINDER(+200% EDF) 25 ' TO CELLAR MANHOLE ELEV GW # COMPS. D-BOX SIZE # LINES d` FIRST 2 ' LEVEL STATEMENT INLET 91 - OUTLET /w9a,74 _ • 17 (2 11 OR . 17 FT) TEE REQ'D? /9 LEACHING 0� f l/'-G MIN 660 GPD?� RESERVE AREA4�/ 4 ' FROM PRIMARY?�� 2% SLOPE 100 ' TO WETLANDS 100 ' TO WELLS `' 4 ' TO S.H.GW Z-- (5 '>2M/IN) 35 ' TO FND & INTRCPTR DRAINS --, 325 ' TO SURFACE H2O SUPP �---- 4 ' PERM. SOIL BELOW FACILITY 104—MIN 12" COVER ✓FILL? �25 ' if above natural elev; 101if below) BREAKOUT MET? TRENCHES or-- MIN 660 gpd 2S�-' SLOPE (min . 005 or 6"/1001 ) �SIDEWALL DIST. 3X EFF. W OR D (MIN 6 ' ) L------RESERVE BETWEEN TRENCHES? t_--I-N FILL? MUST BE 10 ' MIN.-O-4- 4" PEA STONE? _Is- VENT?_ (>3 ' COVER; LINES >501 ) BOT 49,�, + SIDE SZ 8 X LDNG TOT ��. (L x W x #) (DxLx2x#) (G/ft2) TV Copyright 0 1995 by S.L.Starr UILC))I T I I:5UH"A�Y o INV 612-r3 ..%m'CON, ,6► 6 G �p`�N�a�'� ` P PC (M F.J. � c, A p I Z cel a Z,774 r 57.5 z'I' • � 4 �, zsa,zg 2 C Ke-E,u�r• oy' Al N LoT � .� VIA \,U AS BUILT PLAN OF SUBSURFACE DISPOSAL, SYSTEM LOCATED IN Q0V--TTA AS PREPARED FOR Jw d gum DATE: 51 19 ` (-o SCALE: MERRIMACK ENGINEERING SERVICES, INC. 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