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Miscellaneous - 126 PHEASANT BROOK ROAD 4/30/2018 (2)
126 PHEASANT BROOK � 210/106.6-0224 k Road 0000.0 � 1 w Au J s Ott ,. - i •_�� i.7 � �, ui;��rtA�4 n '�' . k. ; „d,s MAR # 1e , LB X; 1t { ! �_ f PARCEL # STREET � 2 �ONS�RUCTLDN_A.PPROVA.L, HAS PLAN REVIEW FEE .DEEN PAID? YES NO PLAN APPROVAL: DATE APP. BY d-ld- DESIGNER: �/ i�j�'//���E-`� PLAN DR-rE. 911(3� CONDITIONS WATER PPLY: WELL WELL PERMIT DRILLER WELL TESTS: CAL DATE ARPRUVED BAC^TERIA I DATE (IPPRUVED BACTERIA II DAT PPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES ' NU DATE ISSUED C /G BY CONDITIONS: 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: C�►S-LSL 1�t.aN y1BLl..a QLZ ��x.. ISTHE INSTALLER LICENSED? +: yet -j, YES NO NEW* REPAIR ` TYPE. OF CONSTRUCTION: No NEW CONSTRUCTION: ,... CERTIFIED PLOT PLAN REVIEW _ CONDITIONS OF..APPROVAL NO { 4 (FROM FORM U) .,ISSUANCE OF DWC PERMIT _ NO INSTALLER: ." ` DWC PERMIT - NO. HEGINjINSPECTION YES NO: ,. EXCAVATION . INSPECTION: ; NEEDED: PASSED 'fJ�/ BY CONSTRUCTION INSPECTIONS NEEDED: '7777— AS BUILT PLAN SATISFACT-10A ESS , r APPROVAL. TO BACKFILL: DATE: l'l BY ... :. _ oFINAL . GRADING APPROVAL: DATE 9l —BY— DAT BY ' FINAL CONSTRUCTION APPROVAL: Y �ysiem rumping Keavra DEP has provided this form for use by local Boards of HeaahOther forms may be used, but the informatlon must to sut�stantiauy tete some as that proYidsd local Board of Hub to determine the form they use.Ths g �� Using rias ' your the local t3 M of He M or other a proving 7u Pumping Record. u� sub Red to P thorny within 14 da acxordarroe with 310 CMR 15.351. date in 4 A. Faci qty InformationImftft u _ . .. p f� iu 1. System Location: on the op nw, Nip. use ONytlto tob ..__..__� 12A Pe,_'34 J� R fU ZL key to move your Addroes cursor•do not �1 .. _...._ use the MwM �� �� yyJCj key. CWTOM —`�' �1p Code 2. System Owner: Name Addroas(�d'dimM trap locobon) Crtyy/rown y . Zip Code T Number B. Pumping Record 1. Date of Pumping 2. Qumtity Pum S` cauans 3. Type of system: ❑ Cesspool($) SeptiDTank - ❑ T"Tarok Q Grease Trap ❑ other(describe): 4. Effluent Teo Filter present? [j Yes EFNo If yes,was it dearted? [] Yes (] No 5. Condition of System: UO� 6. System Pumped By: Name R n e k 11 f VOhrd�(J00r1E,ff Ntonbor --- tCb wy Sea T'r C 7. Location where Contents were disposed: G LSA Sipnratuoe ofHauler Spnatun of Roauvyrp FadRy Dab * 1 OMW.ftf 03106 System Pumping Record Page 1 of i �NORiM d � o 0 ?o�.y • F 9 - • r Town of North Andover •a s�,;,o::s HEALTH DEPARTMENT S�CHUSf CHECK#: DATE: Q LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ 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 $ 'r. ❑ Other. (Indicate) $ f Health Agent Initials I f White-Applicant Yellow-Health Pink—Treasurer r , "'W" t7o-r r^ i a aL i:';i'S' t A; w*t�+ tr.' .�J - Ab'�"�i�1 si♦,a Vt�+, r+.'�, r, t l e .t r,y r t ^b�� r3�'A;"� , ::;r'i.ys 7^i fir. la .M., i !r:Tr' T r:'.a�., .:1....F c�..r('}t'3; hx 7:✓4rs ..n rri 1„ na ti ti(b 1F t. ,$4! frti, 4 •Gir�y f tg,, ta Commonweal .. -. . ,,., �u F• 1� � ,a�,,! s,�i�'"Sar.� F5.;,9r,�4 �A��F� �� ... ,, A7�;L i �..,. • ,.�, ;�F�<�� �•�Qf�Massachusetts ^�`i+ 1 • 7L'M1k a - '..y. .,ti.,c...}' 2 ..y ,. la.: ^Ir i t; ^ rHk. r , z ,,rF A tt:�•iS' 'i`P ro..'.. 11 1 �� ra �s'�� x-11$ _.y y t �ru a•�'�",3! A . a�YF .8w '� p,. 01 ''1 h,,�i'• ..� )--�rr x •t,� d}t{ 3•'+• 4_. '�.',7+F� +ird���A",J,�" �J'Yi"�htesw x F t, V i �•rt �Wr�'�J t Fa\� •': r�; it 5ti of ur 't - ag�yo�. r - e .,�A. r F '�c. 1'4 -c •- , ,r,.o- r .'n ..r '..1A ,. %a y. y' 1 s1.p a yD.r,.....{y riss information Is OWner'8 Name required s , , Drays 1 /O�f� o ; every pa a C�ityJ'roWn ^_, Wu 9. Date of Inspection Inspection results must be submitted on this form: Ins action form's may not be altered in any way. Please see completeness checklist at the end of the form , Iy FAFP y .i Y t;r * impo� MAx G7-: e1] :Yralwee , g out C Info."ation i •, ._ fortes on the computer,use •1.^'' I only the tab key ns P.eCtor to move your cursor-do not Qrlti �fjC'Zt/� use the return �Name of inspector key, rr CL `'�iT/`i C 7t �Ctti V ..ZNL Name.., Company Na .:: r . N Com anAddress � P Y I M city/ro State CQde.11- T Telephone(Number ry • Ucense Number .` Certification a e xr a, 'F .tiK o- - V I cer�y that I ha + p@r�onally inspected the.sewage dispos8l,system at this addre: .and.that the. sS.. li .infomiatio e . _ n repo below is true, accurate and complete as of the time of the Inspection.:The inspection was perFormed based on mj�trainPng and experlence in the proper tUnctfon and mintenance of on site sewage disposal systems I am a DEP approved system Inspector pursuant to*".ctlon;15.340 of Title 5 (310 CMR 15.000) The system., b Passes ❑ Conditiona)ly Passes Fails.. ❑ Needs Further Evaluation by the Local Approving Authority . I -V 7 /o , Ins isSignature Date • - ! ,.. he system inspector sia H 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 systern is a shared system or has a design flow of 10,000 gpd.or greater,*, Inspector and thesystem,;owner:,shaU Submit the ' report to the aPP te,reglgnai offce�f �3EP the and copies sent to the bu er sent system owner y if a licable, I . . :z. ,,. � Pp and the approv(ng authority '"'"This report only describes conditions at the time of insp�ctiont and under the conditions of use at that time.This inspe�tion'does not address-how•the system wH1 perfgnm,in the;future under the same or different conditions of use t :fie 1 ; N4 �rt 4 1 P,..3• .- .r +• '� k, i Sy. Y ,,wh .. • ' U�n OW08 } Title b Offidel hepectlon Form Subsurface Sewage DWPOSW System•Page 1 of 17 i - - .'aak`'1•'`• <�. 3a s!{;x- r;.�tW `<• •Telr �X x 'u?-r r� s•�,}v/! G� :c`�j'' �' 3.r r+d r= ;) yr' fa ,.. ;. �s,!t s, k'u '�„5t ".In"�r{� ;'�,t .. as /• .. US, 'C;;`,M1.�M 6`'4��Y�j1r�Fr�ra eku 7 /Q�. e �ifx�.r'�rrae.�a{r. M , ((((,1�,},'�y., r�ni�FvJ/ %" r`Y+:f, }r�„ s. r-. 7' , 'n�r t 3' td t I -'x w^ y 'i+�lvR'7iI• 61Ai,lUi.�f..f�... i....T l'• .T.. I. �yj'1�' ��I�� 15�3y�ad� f!.` �r'..p't'dAYjt� ta /M1yY�111 u�'y"'F' 4 1 G r �r'M r.,r + f°• •i•atii;�+"._Y•l ipq:,�W�" chuset ks��s'"�•`�'�t t't -' $rt r awa'tre�k{.i{'Gt�Tii q.r.�y ,..1, + 1•'� ` Y„ 4` )s. 4,y r a•.v� f.t,. q S 1 'na- )� pts,u ; air t p r ti e: - t.y�M d�{�� r �) �.• ...rte �'�'f wr,k,.':�ia� 'tP, :�' ay'ti�t'�t l}�++��<hy,��}.,?,.ry,�i�s..) r..x -; k : r i.o 4 7SIIbS 8 N ) oCf�t(a 7X.1 g�a : b!r�t�h 4 ce$sw1age Qisi+ Deal S steM Mn o Yolun As-" W x m F9rm•rNot f r �. 9 mentslit ) ct''W�"L� .�i4t N.'.y � Yti.)''k', r �G h•ss1 {f 1 l'ta{ "Yr 'atJr' Yy f F yh a y�� r a r " sti�rrr u + i r r ( d .a r 2 Ay g r t {Xtr}hVYF°+f y r •c / f'O8 i r. .v . s rt✓ f� >r� C i '•Y s !..•, y7.,. t. h ? t fi�4 �L'rri Ky")){ c )n A'} •`{a . .r 1 ( M,t Oumer'a Name owme infortnaton is YBQUIIed fOf every page Cfty/Town /C7 �7 /O J ' State Zi Code 6 ■/�, Trr,/► lT n /� P / Date of Inspeculon "j w!�II��,.V�`k'q�I . VOnt).l ) � 4r. 'Y z�'L!Y S rr r•,vt`h t{y a: Jt t4 f_ y�t r t4 f... + rxlp �rY. 3 i a Q3 h. r + �. °Ins bon Summa P ry Check A;B,�,fl of E/afK!aj�s camplete all of Sisctron'fl ; a '1 ,System Passes ) I have not found any:information 0166 indicates that any of the failure criteria described in 310 CMR 15.303 or,in 310 CM.R.15 304"exist.Any failure`cnteria not evaluated'are, indicated below.. Comments r: t rN 6 i B) System Conditionally Passes: ❑ One or more system components as described In the"Condltlonal Pass",secttori need to be replaced or repaired :The system, upon complet(on of the replacement or repair, asapproved by , the Board of Health, will pass. j x..Tl Check the box for"yes "no"or"not determined"(Y, N, ND)for the following statements..if"not determ_ined,"please explain. The septic tank Is metal and over 20 years old*or the septic: (whether metal or not) is structuralty;'Unsound;exhibits substantial Infiltration or extfitration'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 rleaking and If a Certificate of Compliance Indicating that the tank is less than'20 years old is available + , ❑ Y C3N C1ND (Explain below) t 09108 r .; Title 6 ofRdal Irupecfrp�FOfRC Sub>Krfaa 6ewaps Dui SY8"•Page 2 d 17 1� c . j 1 :t_� Commonwealth of Massachusetts ' Titley 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments /ZGlug saws- Rr /c Property Address: Ownerrt q 2-q/ _ Owner's Name information is required for IV:4A.1 TWvel _ % every page. City/Town /0-Z7 roState Zlp Code Date of Inspection B. Certification (cont) B) System Conditionally Passes`.(cpnt): ❑ Observation of sewage backup or break out or high static water level in the distribution box due . to broken or obstructedi s p.Pe( )or due to a broken, settled or uneven distribution box. pass inspection if with a System will ( �proval 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. I. System will pass unless Bond W Health-determines in accordance.with 310 CMR 15.3O3(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 surfaee water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh rshu•09M Trtle 5 OffidW hsPection.Form:Subsurface Sewage DWPOSW SYUem.PaQG 3 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection FGrm Subsurface Sewage:Disposal System Form-Not for Voluntary Assessments 126 P6AP4 &.X Rd Property Address ar,c# . Owner — information is required for /(/ N�VC0�$ 1S' /0—z7_/0 every page. Cityfrown 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to r p9 q o 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: I D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ �j Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ .Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow 4orT7— t5ins•08/08 Title 6 ofri"in on Form:Subsurface Sewage Disposal System• age Commohwea►th of Massachusetts y Title S' � f#icial Inspection Subsurfa p n Fir Subsurface'ib System Form.Not for Voluntary Assessments 26 p�Itasa� Quo/� Propej Address Owner information is Owner s Name required for /G^�-TN9outl ,,I every page. wtyl1 own /'1A 0/ State Zlp-CodeDate 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 colfforn bactodain Of ammonia nitrogen,and nitrate.nitrogen Is equal or�less tthan 5sence provided that no other failure criteria are triggered.A copy of the analysis and chain of custod�must be attached to this form.] ❑ r71 The system is a cesspool serving a facility with a design flow of 2000gpd- I`-' 10,000gpd. ❑ rfj The system fails. I have determined that one or more of the above failure l— 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.senr$a#acllit�,.avith a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of th questions in Section D, a following, in addition to the Yes No ❑ ❑ the system is within 400 feet of a surface drinkingwater supply I ❑ ❑ the system is Y 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 11 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.E..� fa+led-under-Section- system in accordance with 310 CMR 15.304. The system owner should contact t the apprroo e regional office of the Department. tsins•0908 Title 5 OMC4 ktispection Forth:Subsurface'%WsBe Dispasal Systam,page 5 of 17 a rCommonwealth of Massachusetts `. 3.1�idY vfvmwy,.� . �..f' .i.::. ` ,•7i �i, .�r; 4f.e..-1,• :..i4 .. ... , ,'Sutis�ria�ejSewags Disposal System.Form Not for VoluntaryAssessments . 4 (mak �Q Propery Add��rttess. �� Owner's ajnet �(?R� req 'information(s '• 'r� ., wired for 0 every page.' :,Cfty/Tovm r, + State Zip Coda ':-,'Date of Inspection C: Checklist Check if the following have been,done.'You must indicate"yes"or"fto'43 10 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 bulk plans of the system obtained and examined?(If they were not availabie note as N/A) r ❑ 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-distenoe-is-unacceptable)(310 CMR 5.302(5)] M'System Information Residential Flow Conditions: Number of bedroomsdesi• n : -- Y ( 9 ) Number of bedrooms.(actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Wo i • l5ins.09106 Titre 5 Orfidal Inspection Form:$ubstrfaoe Sewage giaposal system•Pape 6 of 17 j ` •+ + GU rr F j f /Yi."�I aN?� 'n1F1;rf.F ,� .r'. r.7�:5 }7 a- i ai:d•� Jfi Sn `, „y1 � �},lh +t. ;17,�:��t ,y�i'�'"r �,1:;,t:.';:, , s 5 �. rl Fr �.�+. I.1y'A!F't�r 7Z2�,9j!;'�,aJ ,��' p.M irp4 i is 1. 4�Y%" '�'r; vk- ;r: it r>. xir zX]l�. �Cb4�i' ��'!7 ) Ioe, Commgnwealthf+ f=Massachusetts J .,Is 1( �, 'gyp a t r � i �tJ��, r ; , >r`.2Liy+,i. °T5I7,Y # 4df,4�.;Wry ty':P a I -'.v t ..; l ll..,+ vc r� oh D 4 7f •ryh, ,,-,r ' -.:{� " � Y,IJ�r dr�'. •'t>�ll, _.p 5 s: ..a M iLS r v� , r S',7`f._ { , r r a�04 kip,DA�t s dJ(+r'f`R)e^t)nIts,rta9t .,O l .. tlUnt . �:. 4111: - ( t .1 r. � s r PropQ(t1/A(�d�yy ;,)J �y �►n9r�F 1`i.�r�fl�°�, d!;'t F n� pp/,�p information(a x 1 c rir fti pO /tKl x l y L [ _} 0 'required for every page '" Cfly/Tovm;: State .'ZIp.Code '' Date of,lnspection. r }, D. System linformatlon J , ; ' 1 I 't b 1 i-1-.F q r-I e l I m 1.:1 A '.� i • 1 S P I .-c V" �t k�1^M f Ii�' V 173 Sl y,l .. D� rt c 1�:M (N.:t , Y' i• .n" - .."J_, �. •+�/' a 1.01+. �' tr '' r 1 :,a {`I��(1pt n ,�. �{J (/,.L CCS. /"�.t.(�, ,� �• - . ... .. Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a Separate sewage system?[if yes separate Inspection required] "r❑ Yes •No Laundrysystem inspected? r ❑ Yes No Seasonal use? ❑ Yes [N\ No I a ,Water meterireadings, if available(last 2 years usage(gpd)) ar 'Pet 01 ' Sump pump? ❑ Yes No Last date of occupancy: � Date Commerclaftdtist W Flow Conditions. f1 tat rrC-✓ -r- -r, .. 1 , Type of Establishment: Design flow(based on 310 CMR 15.203)-.,.: 3 z' Gaitom per day Wpd), , Basis;of design flow"(seats/persons/sq i.010. ) Grease trap present? ' ❑ Yes ❑ No t1 N Indust 'al waste olding tank present? [] Yes ❑ No i t},'� r Non Sanitary Waste discharged t0 the Title 5�� Yes No 'e•',f( 1 _ f; Water meter readings, if available: pgpg !+ 711M b�17da1 hepsctian F*8ubwtaoe Sswagepteposal System'Page 7 of V ' � rf ., y.} c} r -a 1 r4,f• r 4`I > -.i b >J�, ''1 4vl;. h R_ I r' ...d i if..' v tFF A,a t d ie t Y.. a rf - y� L K �} t e p >g t±:Y`7a a ,n�{� .•Vit.y.;a> fi '` :ay! i':Jiigi t ( ��.qt u'... s! r•..., tilt.\ ,� »r. yt'S...! F a1•ry+i6 t"y '"' ,rel,,.- �. "fit i ;) 1 ,� „d.^•C{ `e t ty+:t.11., ;. ,' t s {;..ti 1 --,,}, '+p .,.'r' c.�1 F It ,p .� t nc } r ri T'd1 a. W d 0 F �,-•'r, x r{ ;. ra-,.t a. X[ ,, r: r tr x r -h' r..r.,,. ,ph't'c' \1 -} �i r f +r,,,,«r a ,i A"�\i, •r,kY s.NtA,E,,�•.`r''' �.. F 7, w ie ! S. 3 x'd e . ' %i .)`?�l�'' ;(g + ,��,tr 5nt t+r a�hf(<z "i r ?f E t'r I rj K=, � r;4 1 r a tz- t: t7t "Jr1 '_`i�,'lry .�..�. '� '� ,<{7�h'?'. �Yt'{ •r`T+ ��r:hrrt r 1 '!]e;f S '",id� �+a 'n� '}iF ''?k . , yt f y .� y: on eat > $ chusetts, Y, � rjU—� Mill � h s; xt s'--•c.F. d q t �� �, y .wTlfi•,i,;. �T. <7" i[ ?t^ rA sfy'"t�zt+.1,•prt I�r t3 ; r..�, N! 71,.a�r Y 1 �,+ w 'i ": :wG: d a 1 � `�' �tia"+ di l[,'N\ >gr d ��,y"�-.. 1 § � } pa. r. Vit;a ti'r!'Sp ..� o',> s- ...t. „ I . •.,LAY-1: ;�� " ? •, +`�* a r., S, a.Frsa,. {/��. •r+f hra'^S�fk t% �i•'r*P ta.,yx :t•F Jfit., >ti n)L.,* r<-.ti a ti'r s r. ,I„_ ✓ �n�� ri'1. tH � � �� #aw I.� M 57'M�lyr`}Fi�, rilF i d 1. q.l'jL 1, ) A ` O}4 y�Ya F Y l Qt 11 t .figs, Q „ $ t '4� 1 s\ by t v t v is _ �t .�..'at'Wiiti �,f t,4 Nt :rk,'t",G,7Y } dd:li. i f if e. A`3[iti '�rY :{.yew F�.�q� -d i, r 4, .. .1 subsurtaoe Sewage Disposal System Form Not for Voluntary Assessrr e►!ts ,{{�i1 t .. tf t-,k + tZ }t(s,, a, f w. 11. ,� } ,L:r ,�, [.. ,s,. 1 ^,4,I.... v,c ,,t+ f j -+ti 'r r.[,t ,, {\� 9^r pa t�,t3 gV';gJ;.,M1k SY+} j �P.'{�t{1 _u of ' t ;5:-<r 1// �,�Y 5 ffT ��'i a Pr 4 •3d} t�-p f f t.. .., F )I 1' l4 Ml/r } \,F t 4' ...ti f 1-C1,L•V i 'd:: C �'�' F'd'f+ �'' / ' �.- a.i i- -Y �^..r. .$ '1ci3 ^' 'La)r i„ ,,,-,,,-.I-,r'1r 1S t �{aJ"� .Y"�it-s. y�w.f:7-.;,�jv yfj,,f ',?,r c �'. `�D� piGQSQ�► gid= f� ' r ,k«' '�s�", f t "� s4 :> ^,t ,a 5 �X 'S'r. �, h24Fa' �,tt IiF�{ + ,� %••�,-y +-,a t e.:t k E ,t igv�y .L s,,;,rz F4 .r a i- 7 r 3 F Y �r r ! y, ; }l n r.•!tX int y,+ n'R . L rk.`Y-1 11.13; , dk.Fna p.,� 1 ..!t .}4 F 3 +, T g K , F'�r V yx t4S�Jf, '`t..r rt-C".rtf IM- ro ? i�'. 't t",fi.:{':i i �i. J�, t a.,t 3.. `;+ tit.{�F-1 �,j"' n. .,4 d, f..-+r%'7''F S V?'`j t1'}r�,X fir�� �q'^# ;Hr.p°d n F'}r,:?1 S.:", { ,�• G)� �' '�� s It}r �,'+. s ;,r t s , ~,1 V 4 s } hi_ y, [� 3 a '7t fi4 T 9 .,Cr w t —, ,a t 7 tt4 6"i''J J,-.. ( '�'t t l+s,re a3 yr,� iP 1 n r. '�, -{7'' 't� a"f�i r, t!•s'aa "� 4'tErQ G�Mf .T C f r�,T ,t a� i„<,.: Cv� ��� r�1 .) 4{” •i i.y�r-t4, r �er,. \ fN .L1 t s a - " a'� k*+r y r tr ti a ,t s OWner'S Nate "t t� r t1 �. i t , infonnatlon i3 t y r Yl., r '' ^ G '7 h' j1 hesP�cr a :•' r ..required for 4$t11 1.r /�/ ANb& ,(_ L- .1fll_{ (/J. , ' r ,s,;' 0 G•z,`1 F 'eve a e ` C, IT ' . '` 4^ °-> State Zip Code ��":r� Date:of inspection,, . ,ryP 9 % r � r 1 .. } r 6a �^ V rrp.�(p4 i'�4ykil. ai'b`v! :i+� tY • g >'}`e g - � D*i�I „` O ' Wr�``/ ' v +ra•. �t 'dt J'f':pY 7-tx,,4F arty,ptr�*� j t>Lse� fa r , 4 r :1' . i:r )`- y P �. ty�}.Vis..,.'u�y1 , Wyv'x.vyy����p`.7y�,u tCr C tYli:,y f r, -..1'fix g,r^'"'rid)+ r ;u,'„�LZ(i}.Sx�',C�`f'rr"f6yf'rRd!r„ ry Ft"cat y �s v 'y YI C �.'AL �rt4•"{} YH .Y �' � 1,,4•RY7l"'7'S fK 1 5 r'K a' r -S �M�LhY { Y L `5 F aY �5 'i ..w r y'r s Y" ,,. 7 r- sR1 t x �.I- �'.+t, J✓ r F - ,t frt f c. uJ ( ,� ^`tom, 4 fi ir'c F r {+!}i \ K. `( ,r t '� �.!i y{ rih R •*'1'�RcNyiY,}'4 `,(i h,d4 ... t s 5 s rl t r'1/'4 tr�J q,Yi h, 4 - t i :;Last date of oxupency/use ti ' .. , ,„ :Date X 'sot t ` =� . ' • Other(describe below) I a + 4 J.' ,i,1 t �. ;, k y i � ff t i( f {'r I t r t +...,i'. z' .�r 1 r\';S't5fiL"srl r n•{C,f \�1�.. "s' 1k f 1* .. t y t t ,,t ff t tx i r v d •Yr ' { x' .= t,it N tr i \y'r '� r 1 t tai'"� r t, ,±- a,., - ` _ -C i Y F t t=1.:r} 1 .r. 5 6'.,.�J :t 7. t.'.;'.+ `. F 1 t ,f IY. r F ! d : s:' r o,k e .S� 4 r fr r r s yt t _. �t s. C'�Y d 1c tr f at t F< 'I!"`6�� � i, ,! r General I�formatlon )...,�. 8 •! a ✓ 'L�'t:r.ai {,+K :'.�.'. '.ay'' ,, t o _ ±^ ..x t t?s �.. r I r Y r Pumping Records:':, C F ce of mformabon r �Sour.� 4� A r t 'i ,' ,f f l�h 1t# 1 ,�' 1 Y Sf' ! .,'- . - C. r 1. 1 f., , ` >L�Was systemp pumped es part of the inspection? ` t�, r�` yYes ❑ No - 1r� S ,'.kJ.>Fit " y,�t .r�s"�J'kl +'•a `ga .yi t t /�+ _ t .. i 'Fi+ 7 a ,(t a - .i r 'rs-yS♦ ti 4 p; '�1 k.vs•'.r.,Fr Es..) r1. __�lJyd , 1 1. - tt .,-._ �. .;f,s { r� , If yes;:volume pump r f gallons �r., :,, . `How was uanti -r r — '.H,It ,,", um ed determ'ne ? /y� P I d i. � +i1� d 4 .1 4}�.. -:5 iV .pi t r „ea , 1.r�NL :'r r)r iii g�Crt 1 e! a s F :Ir . ,,, 1. -.-1 .,;:' ", >`ys. r. ,! -"t' '^ p .wtt�,{! `;-)j;r :Sl,rx, .. F + 'i 3 iaa �1 U ,„,,Y>fi c, �: - ,a ,s --: -1a l ai r t !+ '� C UN 2;1 S r,a�. 'rF'rSS+ d' It.1'p�•j`.Vt i4. t a 1y + ,:.F s s .S wtr `�" ,, C s4�.xa �" ::.: , g ''t*' I'Y'11: !AAM- `nkir•,,t.t; , . y..-1, .aJ ts, Ir r r , =.� Reason f}orlf, um�ing 'r, 1 al. f'.', If;7 17 4++,it �"/g�4' ¢A"�+�°.�'•}s'p , 1rY ! % .✓ ) ` .r s + a'ts 1N ti f it, ! r t"!tzP° M� x N ,-- r.a' , ,j , r f t 7 x 3^2 r ,, }.g r ,r .. } a, .x.d ,i.t.. TYpe'of System: t - 1'� F' t� 1 l.t.�� . ,I . �, .:,,,� "%10. . . . , - - - Septic tank,distribution box, soil absorption system_ t\ ,\ z. { � F J Ei r _ x j��f,\ 9v_ -,r y t:'" '1 S y s{<+v x a.+ <�. fb U i t. - } {r s t ^ :ir f n3 c.{hipY YIr" { 'r :,k.,r...,❑ Sin le cess l ,.%. �'. 1 ter 7.{ r M a �, •i -,� "� tit t 0.' it sr w .b <rc," # z i �.t-y�fr1. a p er i�..i ' r t I { t t;�i rt 9aY[x1r � > rr�k r�JlVrf y a.e rt { 1. Hy}WIPII VF . . r- , ' ' .. overfloW cesspool1. . 71r. ,,'� , , r t ❑ pj n v y '11r ! , e a +r 1 r s t.i° x t + t t 1 ;F- e rri.,i�'A -ItS yll v,;,.J,-11 i, 4 +,5 t r u - f, '`"+ '1 ^y . I a ♦ ;.1 t Ij� u 't!N , t •r• •y 5 t .} t Y -h'lAY"S L 1 '( A.,K . - i .r�yt,wi {w*.,NRSt a'�• fw tr'n y,t. 1. ,r ,� ; {P.y47.r.\. >. .d'Y•F�o'Hl ui i .Y°�ak .. , � ;�r. , , r ; Shared system(yes or no)(d, es,attach p�eVious tnspedon'records, �f any) a. a tri - •':} ' ,.,� � K��.r.id-r "t+£L'i' '��k�FHrs int _ •:. ;t.ltrF3•hf SI.cjkR$)„ S6, fJi{ fsL,�7.y 1�)krt_y 4'i`.tlra tat".Ly y+r, J1.t.x - . "d 1 " 4 .t i �f,yi,,r,v rt- , •.:.i' ir. s .,, g .r•� ';».4 zf 7 w_,�it'1'S�,d ?:F R.t:f°q�y fg�-: `}� i.i -1111�r 1["5„° . ' ❑ Innovativ"tem' ' technology Attach a'copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspaCtlon of the I/Arsystepi p ;$yst@ operator LI dei CAntfdCtMF «�'t" g J t 4 X 7. 3tt ry F' ? Lrod° .rt s)s q� `i �fsx fS'a is �iory f# y .a �Ya{ P�lrt pty�� ! -;. .,� ,.f' 4-r`YI+• f rz�'n i�'>T�"tF p$r7r k}r LY.?' 15`f '"Ti?Ya tt 11[?,,,4�J ;1'111-t ` .,5 ff't �.y r--' J h r F �. t 1} 4 S,i;J�3a t4,,.. ;L�y' : r T+t 4 ,lS,ski}�..i}5 a.,' }p ti", i 3:rn +,,,-`jr"I`N{���Y�i ;i , r❑'`,d r Tight nk,'Attach a.gopy".of the DEP ap royal t a A c' "� t 'ate - a.', k. f : - t�h \Kdr h..y t a r 7 r tY, f"_ i a yl f 1�t u£'aEF� +,iJ' r�n•5}c.rrrr ,�iyr3F . ro i,s �tF+rk, sn .."rltbrirr�y+3 . .. 'ei -- , t '.��r.ctti y 14 � 4 t>.ffwFx�6tr r ..-J < a 4, i -. $ •� ru` Ch.y.} 5 ^�r a �, !: t\. g, ..,rrct r xe n. .f •. ) n. A ...c .:.q.djp,... ,) v,,. 1"+ tjr r:,yp u/ r+ ,,,.. k .,s F } xa`!:' t. i .F ti,-ap 1 t. a t ?'},2{S.�j.\-..� . . ❑ r Other,(describe) , u t r lk . } 1 1 7r ) .. r � Y . r 5;r �,•`�5}} S'.t`f !} F s a "•4 tt�(J�. •^�'S,5 ! - ' r. a ry kx}�.ai l.+s. t,r r, `p y')t r X;• ,a 1,sir,hF '', •E 111" }111,".y„r�'t-g, 5 i .+?'. %r .•); l t n,4' 3,✓•,,,pyr�f to •6`-k'i"•w 'o t 5� 1 r [) 1 �`. t k , 7 r Yf17ar*l+�.Cbrri• c%Ai1 `r ' lSMlt os+oe t,, y-j � -F r. *+- r6gf's} szrw ,.ttF `` r� 5 -7,La�at .� to s x-.,,aeaY r. .•;y^ )�'i n,} �i'iFiR.e<.C}:1F'�}� t, =•.t.:,.' Y, � a r; y ro ,,rt 1 ,w � : 7 . 0, Jr otlon Fae�Subrurfaw oipFo.d ' 6'd 17 r n ',tK r t.: i N t P i r�ir-i'?,+..tc�.t�"""�'i� , ai7- i , s ._•a +. �, 'P d z a• I;f,,a 6_ �*"'T -✓ ti tt.�'n tai t [.� 1. k�''C� ,�..+`-tiUT.s/41 1 F. t. `I S..;� J�'+,.' �k tE,s f t+x'.fi f�tvf,Yy'rv�. NC'Irt♦♦'}','ti�j} 1'*�t.t1 Fr p y '.1..,s ± 3 .•� \ d: ..� Vi G. I-,,.a �Y'k. r')t§yy;.} i1 ; .t M i F _ _ A4 t t !i ..a)r{ r,j4a gPFJ, yr!#r n,t 9W G. .. p. ! j x y., - tdrt�f;: 71 "r,:x Jxt' Sr..,.ri j¢.i M'4ck-i �M+.._t., 4+'}. - , M, }!� ,7 h tyet Ls M,"' 'T., a ffn r._7 )t"3c '�h';xt 5. 10. ,? g. _ rb.,tigw l Rs'rl7. v t,.z 1 ft. 111 to t r ns3 , Irl e. "2+, t r S�Y-Nti.YiWti �l� ♦ .r',.. f�,,s;` �> �p mgon a o tMassachusetts , ,� r ,, ,Yf&jy\i ,.w r itie i ##ic�a ares Fr ,Subsurface Sewage,Disposal System,Form; Not for Voluntary Assesments v rpt 1 r - { �fit 3'y;, r t r51 ti±l•P { �..}� "��ttr � r' - Owner Owner's Name information is required for /1/.,f}wpoycl A-4 ©AV I0- every page: City/Town state Zip Code Date.oi.inspection,: �DR'3ystem"Information (cont) , r , 1 s, �Y ,�p�y J �.�sl sh. yvy x, �� ' , a v. '', �•t f � Approximate age of ell components, date installed Jif known)and source of information: Were sewage odors detected when�araving at the site? ❑ YeS Z No Building Sewer(locate on site plan): Mrd. •7 / .r .' Depth below grade: feet ti Material of construction: - Mcast'iron ❑40 ijVC ❑ other'(e'xplain):' Distance from private water supply well or suction line-, fit .. '. . y n . Comments(on condition of joints, venting, evidence of leakage,`etc) +; _ t , Septic Tank(locate on site plan): Depth below grade Z' Material of constriction: concrete r. ❑ metal ❑fiberglass ❑ polyethother ylene';' . ; ❑ (explain) ( P ' l \ . If tank is metal,list age years is age confirmed til a Certificate of..Com liance? attach a copy r) ) Y P ( of certific/a�te �[❑' Yes ❑ No Dimensions J Sludge depth (film•08tf18 r:; r + '' r� � '� r Oftkiw kvpectlor FamF D Pape 9 17 *.. Sub�urfaoe Sawape itposgl S�ftem• W J 1 "k"`°�i�•.tb, •r w7r. J. LyCom otivfealtti�Qf Massachiusetts r f 'r' `` n £ y 4 • �ri ' `Y �' a° ::i - ' Tale 5` ##�c aj-,-Ins et,ionTo�rr ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t4 26; Y n4aros8 L Owner information is OwnerS Name required for A hW DOvc< / �H_ �� every page. Cit�rlrown , - state Zip Code `. Date of Inspection D.,System Information (cont.) w Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33 f Scum thickness Distance from top of scum to top of outlet tee or baffle 2 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): /1/O S i9ks o F r `i Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiber lass 9 L]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 L%W•aaoe Title 6 MW irupooForm:&AW fam Sawape 04poeW SY%t8M•p890 10 of 17 o 4 ! � r i�y7r 7 �:, i.�f'7;. { J17• h._a�i',�a.r`,,"� t1,::�t - t t,., y .;J z , p'y: i rfd�+,,,:a~�,ei+, i n ,,�k ?, CO M.0 of Massac�lusetts a: '3a,.+'(C.kSxrs•fril ,r ¢ ' le 5: �ck s tion P �•yA� 5 .J A t:.y Subsurface Sewage Disposal System Form Not for Voluntary AsgessmentsKUM ; l y: ;. y Pr'opeftY Addross�� Y �� F S , Qwner Owner's Name information is �� required for every page. City/Town On State Zip Code pate of Inspection J. DSyptem Information 'Comments(on pumping recommendations,inlet-and.outletlee or.baffle condiL liquid levels as related to outlet invert, evidence of leakage, etc.): on,.structural.integrity, 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 . Alarmaevel; Alarm in working order. C1 Yes ❑ No Date of last pumping: Date — Comments (condition of alarm and float switches, etc.): Attach copy Y0 f current pumping in 9-contract ntt act (requi red) Is copy attached? ❑...Yes ❑ No eek,.•oaros s. Title 5 offkW UttpecdM Forth:subWaea 8e11pq 04PRIW System•Pape 11«,7 Commonwealth"of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner r,c Owner's Name information is required for /V'lq'NDOV-(/ every page. City/Town �—='— �SLL /L 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 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.): Cmd (1,10W,10W Ver`� Gr�V/rt CAr1ry p�eC 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.): i i Soil Absorption System (SAS) (locate on site.plan, excavation not required): If SAS not located, explain why: is ns-09M TWO 5 OffidW lnspecaon Form:SL"Wace Sewage DWpoaal Sys .Page 12 or 17 4� � ��„t ,5:,6. r?;j�+,�t,sA,• '� � . h ? Z+.�';r p, fr 41 i n.,-It Sir L t r 1t `£t.J'Yia1 t •✓. J4 mak'.?.+ R ?5 :.t t'. 1 fis{✓t.ott? . . {','.� P't,.•s �vy��;�+ p,fja i ny rt Y +,' - r �a 1l.rhT f Ca ,iNy r 4r*-`�y6 tiklf 1 ,,ta,6 T'J [C i✓ t: T'kU'••D'\ r� .p� e} '6� '!�R•.. e 7^ S. t 5.. 1Mr L//''►►. 'i A.:L � + y. .YJ'�k. /1►. Qp}}Q:yP,<,Ir P4 Y s=s 1 i)1� +4rr-'nt 9 VPAfSa'f? +. �Cy'µt(j "m QMal �Qp 'rvn. ,F, 8_OchUS@tts, :! Uit kti*/srp .'oa�y.N.V•iY' X14 re `a?�,�``yla 4 t Q Q . M t ;:,n( n- Y IY�� �r, +�Y�d `�.. rK �:'�.�`i.e IF tj- s •' s _*t�' y 1.,k. i P r " a Subsurfac Sewaa`Disposel System Form' Not foE Voluntary Assessments { Vlii uI .b .f l gtk.+Sd1taa4 two, S: , e��1�s�h�^+ ,; d,<�:+'�y,�t t,i"r.`�.'_�,21, ,/y}��4.{'y+ 'w��i{•1'tlty r k.c„� ,r r::+ "k^i A r ''u it yt t'y'.�r }tJ ay., }�''r iF 4[} :,,,t ti' �+ 33i @f' t z,Oumet's N�a�Ame # u`? rc. i✓ J"k 45 d '1 �'Y informtio an is ,": f Jii.. /V'"/JN�V Cr / 1/1 ' O/.6`l required for . { - Sta every P 9e.a City/Town; to :=Z(P Code ` +' Date©Inspactlon -t L fo\ a 4` < W"; 13I• / S �µ ,y, i� f { Vr°4_#r ry°..�';�, il�lfi} j+§�i',+� r'iYlt0�..4cont) iSK ifY1 aVi Y".j1 ,ateY'{Jr^''sr i s .L ,�k;r 4 ''i• ` r. •t :Nk,'ak'y�eii if t{ a tr �` L 4 , li7 r r�u''ArSF+ r 1• ,`r t r�.f# rf �tr+17F{k. s::,V}�`�k� 4Y)ii�Y'3.<ar �Lyd hs}� L.txrt r?tf Ytka5 . r V + °ryv - 1ty .,-1 s•, t [ .L ift kn •�}�`S^t}l£Y a..f>1.� lz; rtV t¢-�r r s li: }t..t s:t ,, 4 a�.. .V t t:J' r l;V2,,rfl �1 " Type " ❑ leaching pits number: leaching chambers number leaching galleries number. ❑ leaching trenches number, length .. ' 7`� , leaching fields number, dimensions ' overflow cesspool number ❑ innovative/altemative system x Type/name of technology: i `511 V J 5 >�Comments(note;conditlon of soil, signs of hydraulic fallur�e,''lovel of p4�t"di ng,'damp soil„condition of vegetation,etc* ivd S 4 1 � a "'Cesspools(cesspool must be pumped as part of.inspection) (locate on site plan) Number and configuration ..r fA x' a yy r-, C � F Sr Y.:sr�g� ("fit !•. Depth top of IiiOld to inlet invert �} fp t' Dipof solids layer Depth of scum layer Dimensionsof cx�sspool 1 a_� lr / Materia ls'of construction Indication of groundwater inftw ,$v r , ❑ Yes , {� No /,gyp iy�p= v:.jg',.INrt �wg F P ; \ vr�'7 '` „r,y a •A,, c t 'thp�'°r.4'1€�'A r },�'e.s i'y4:•.,. f - 15hu 0 { S !t a F J Ly k* �v {'3 14 K'iS af, 4 bufaction FORK $01Mi�Q B�IirBT•Pape 13 d 17 * f .. _ s i r hn3*?�; Mimi prt� A l55_� d 1y�ytx .}�. t . . _tx •.ts,.r'�L..�r '1roCx�a : `. ti�i,.7,•::'t• rt s,�.'r;s , t §,,a. ii,�`�•?��i air"'.,,{hr E.k�{ ,y,r„„';,�.,.4.�'i.1; 1 "i yt?.C.',,.t-,�t;n �'�.:� . .'B, �:Y• .t. T., .8. A rt,;.4 nx"t3�ir.� � 7e, rui `<#'dhF�� aE("��?�"RSt�`3��Imimo w��ith 5f IIAus� , w9 •.gf ft ^5 t t,�r • hr'-S�� ��ip4�p` s�'y# •I J `rCt x' ty 'rTt, i����'{�N,f 1N � �M"�qV ,e �r 4.. +t k� '.�a a1 r�r. ,,�.t r �i r i r`.., ?{ ;.'..: y '�.;y S "i. Subsurtace Sewage Disposal System Form Not for Voluntary Assessments' r A y c i i q tr i 'ay�fl rr 1� ��{ Y ��`•l.�/^��,t``. ,r^(//y.�.l{. pL�' f4 s ,� r�. } r! •#; 5 Owner ,owner's Name y information Is ; required forr ^i9nipavt� 114 018YS �f} IU X710 every page CityRovm `4 a State zip Coda ` Date of lnspedfon D; ' I yster�'tlnfairm� ion (cont) } ` �� ."�;. C Ar• T IT �^` F Yet Tji! y+ 1 j dE ld t u•"I r ..fir Vr+ „ 'L L4, => ' Comments(note condition of soil, signs.-of hydraulic failure,level.bf.ponding,coridit(on of vegetation, etc.): Privy(locate on site plan): i Materials of construction: Dimensions Depth of solids >{ Comments (note condition of soil,I signsns of hydraulicdrauli c failure, level of Pofndin 9. condition of vegetation, r etc) s : I • P Tftl�8 OAldel YuPecgon Form.Sttewface 8ewapq oitpofd System•Pape 14 d V li' li Commonwealth of Massachusetts T.M.e. 5 O ficial I-n.spec#ion form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti l:�'. A�4,. : Property Address rt /. —_ v�tilre42Rr Owner Owners Name information is NrOI�Y�., required for /0"Z7 /O every page. Citylrown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of.the.sewag.e disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ;:. where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately- t5ins-oaroe Title s offidai kupectlon Form:Subsurface Sewage Dmpo"System-Page 15 a 17 i 1'ai - r-ar .q a R .:3". °Y -1 '.i{ ,i1'." °'s' y "T r t'LF�"t f tiP'Ig'Y ), .Y-a�/ F 'A YI'et lr :1 �h ,,;,"`rA ,'�s i+"{` t..'1.` x -e3.:.. F- µ:4'x t' `'v'>:r�'.fe `�t'.xs3' 'I )!'h AVI yN v 1,'S'4�v4l: frrpa„a,sa. ✓fa ;..+rY'.+,- 'f:; a,`:Ya�,s r 1' r#- ^ ,. 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'�v 3� Yt' $t " ,h �'h err -.f i j� Lt �'j,y�' rj, �. .� � '� S'. a �st'iy"-rp/ gfii a / x4 t 3 y 1 :.'r' fYvr f'.k"".rv3:si y �tJf - iU.:tN { `,� IF-� �r � t. wt' r '�"`t 1 -k a,, x E:r 7r tat �].. tt��'... ,!" t.P., `�.air. 4 •R**;o Y i�.".Ar �r � . ,— f s h t ,_ �,',U urf Se as ;Dispos I System Fo Qlunta-r, ' i ` ":j "$,*, �, r A tl A !,I :-X 17' .,' �'f yyMty ,H,a:N%r ''FM. ,_;s rG'.. :f'_ '� ;M z,i-� i us P .'�s 1 � V J,+f,0 1. r t t`V tlxt^; n.^!,K+„�r�k Yy", h1 'j, ��.; ' t r4�. r�Yx,V;.:tty: C .xi' :t ! rP+' ar t I te+N"3"r S�>»- .�:.ii••'�'+f^�-' ;a:1 kt•' `43Aft• IN .z: Y y[� t t r 1.i4. -vtTfi,/,iY+ `Fo.:k^. x. iRj 11 ..�trfr"o ,� .s`1�; t. iw rw. ..6 i7 '1�'..ti}.` r-.. :.R-r uKx,t •>r l Cy+ j?Sr°j�M kS- r+. �;. .�r� z:. +�s rr; m v�k 'vr yi mss,V. . !°� �,/��r ,?s 'r• �vtW ��� S yyF �#Sy S�e �'y �¢ J� NNa. eay �k et 1, x tiz LU'•�,,.t _; cp.uE. 10Ar'.',.1�s ' i . �w `�'vlt r" 'rJ f�Sy u.t. 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I sk x ( q^ l; t fi � t�}�t y�,i d ,t. kl. f'r• r ( ,l .:t�uf,,,a >: .0{, i�yk�4'' r A£.dtaF,,Y,; j+�iy' �,*„tG ;r,+Yy'� ,r,+;."7'W' , £ Site Exa - ..� u 4, � ^: <, � :x t ?. m ;.� 1 +. 1 ,t + fit �'� y R yr< -f�9 Y ':.i - .. •.t.( kr Gr}'k /'t r.;. .1 .0{,r., ;"* � - - f.:r- • .•+er �,* Y,{k1 ,. 454¢y t1.. . ;t y Y' , 41 �»<° Check Slope `''� Z , r t r 4•f k x r'• $tt:.� tt �nA-,tr./� 1 `t' s 1, 7 -y-: .. . 1 r .+y r }+firr.. [�t�SUti~dCe.Water`'ry 1 , .. a Pa. xc- r dr. V. 4 . I '1.1' . a, Check cellar .... `< .. r• ._ .n z>. 1. I 5a- _ ,:•y-, t / - .. Pa, d i 'l Shall w . o eI C�' w is. .k.k . . c r '�4 - r. ^T + u 5'tr ; r- ,t ... s. - � r .,s,.-, ria .fir , h. r t. * . •*�,.- r u x. r .a oI N .Cil T _'.'1* S -.,.3 S t- d . ,f(>'rj t',f( 'F qty r 110,1�,t r _ r �l/D 7/ r"�" 'Estimated depth to high ground water �w. f G ; ' t3 .t.' '.. 7a L rig 1 - t 'r. feat ✓.'"�•r""+'tf 7s ,rr 5 ,, f� - - "� t a 7 :.;R .w'¢ `..-. .D e^,,.,, - CG e r� '.y. ~ ^s tr'a<t rmj. Please mdIcate'ail methods used to determine the high ground water;elevatt. -1 ', T F�+ z -: : .: K 5Y M ,. . F..,a, s.. �t✓4 t-,, V.tau!}. f ti 1 r rz,w 1 t i 1. {r , ! Obtained from system design plans on record h ` ' �� t y ��� r r '" �j., ;+} , x,t,.��tt.-i. df s•khq",,- "'S.. -- a } n a i i_yQ Qt 1'ra 3 ary ?. f tp e w i '" +r?.•.- r .. - ..+,+ ,S. ,r r .. ,Ji mbs�'a:�a a �.-Ll zl�..t}y,'' t'8fi r �>r .+ r s �, If VnI1IGGWWIIed date of design plan reviewed a y �, I S t: _. q.. 7 Yx' 7 .� +'.• Y fP f fr _ 'w,'�/ a 'k QBta 4 iil.t t r Shy Y iaA Y. -'' ,. ❑ Observed site(abutting property/observation hole~Hnthin 150 feet of SAS) y 1 Y :, y il, j ' + ❑ Checked with local Board of Health. explain ,1;� "° ' i � if, 'If , , i"` "q''r �':.:.-,° o «ki t',,,kn:"Y T r a z r r _gx�y �t r Z t,u t ( � # a r ti`- 1.l f , - w `f ,",.. ,r l'a 4 1t t 3 'l u z' �ra '"aY .a�` ❑t Checked with local excavators, Installers-(attach documentation) 1 �rfz S k ` f r'�L ,i}1t� 1f ❑r Accessed USaS database explain r"�a `4 ( ' 4 i Ri Yr i.'� t f i �:,.,t rr "''" �4ft.,.�b Er t 4P sk:t.1 ., fi a x > F 'r R, r{nkt c 3 pa, trl 5 T ON c .r. w „,., }, . eL xp;�i 1 r txtO e 4 ! lit z� r>:rt �4 X t..-si r,. k i F y _, y 1 zt ? ! J hYou must describe how you established the high ground waterj. ,elevation � ,y p�ih rgf: p � f,y! ... .' :e ;at "r rt xAz{r'I�j4,; r� i., _ rn ` rr 1 '' t '' ({1 °fir .{, +''i'{r�t.b� w - '•t 1 +Y' tJ9# + c t t'z' 4t5,e tirfr t'z..( Y1dF k`i ri', t -....r`* S r ryt aj! I h -t n_��Ton�'#,r, e ,tr Yta n - 'a.. w ' !v 7 H S } ', r tii %.iyt x ar''}! I' p.`t;$r "'oYPP'*�.a ) +r+T7 w �, :: " + t %r �- t u ,� t r* rR k-.�t t`• 's�YSI.�aA, < #c °atc taro t Z } b r j' «� f,. .'.� i t' tY�TL" P'.c 1 ' z t } ,4 j r :4' r4 t - t r'S. +�R, c t. av ,+t k,rk rA .�, �f:�.,�-`�' 4+ ^.11;. ,.'; '' �'"a:, s} a�:� t r�t'1"'rr�Z'y'tt�€r� ,�.�, ?roe.;-, ,1 1 .. .� , . ,t'h 4 - 6 i7 �.^`�4 1rL T h "x'-i1' . . 11 11 I - - " 511 3. '< r. # ». '� r �f ti.W. �"Irt t T ,.�: YL 1 ° X cry' F �I a44+µ -�^Y Fw't' 'l L M"`"' 1 r _ . ,- . „ ✓ "rt• M _ t j ,t �M` " x ,� �,.., x}3 ^'r, /• • L x:{ia xn {�wk . . 1.f .'`Iz1N x }•s .. z r14'µ - + .t r..- >4 ;Y r. - r..q; f . i .t - - < T..r k J r I Q p - M1 ,,. - G x 7 } ' , �, .., 1 -,, .taC^tr,t ;4.. Y +e,r..i Midi",u,. 3.,. { yk 3<i 4���;u,^ t`'Y' '.ft'.t,i ' i, 4- � t Before thing this 1�1e n Re opt , • . :i� ,fn� cttP leasewsee N rt� er1, he t 4 P 9e.. s - a ., .7 'mat. /,,t!, t tr ?.y'a.' (n >, e ut ;. x p�1 r P P RS Comp@ �, r.Wai n next a .��� w''r$ y, a A3fi:�,, 1 s. fS r � `1a j4: r P i a > '4�. t .,. a �. � yx -t.r�,v„r "tri tY+ +714'r4.. y .A an: -r^� 'Fr« t'� r-'i'' ""s�3't n.,ryt.'r+�' n rkY'X�at, t' ia .,tr �. -? I z 16M1i• $ y„ a : .3'`a y/4�i :,a 1� •`q"?R '4^SMP` ! "'raA.� i'+ $fi .h xS..a'+...+4*, " „r 3} S« YA;-•Y r „P'., 16! • ">` ,r�:•pra�4.R*n� ,}I'L:s s�.,t•Nr .F'T,r T, .yr.it' w iI,.t "''.y a r�.-T„s .^.,? t a: ` + - r, r a onFcrPk 6ub�a+rfNo�$drrYp�'OkP9iW Syatan Pape 18 d 17 - 7 t.' .., <w r a° a }.?,.ryK.,x 3 s, ,3r d ma �'"' t r t.€,*�`i ,�4#`-*-. ,.G, 3,5-..r '?= ,..t t. y r / S,, ,. v 1.i a '.5 q. 1 t a e `*h 4 x }t ro f it 7� ¢ r a1� ! rs 's. t ,., rii:' z I . f. It' "": y .#' , 1.3 i..L . Tt.f J. r 1:11 ; = -.m , y a.,Y a„ta M E i.,�... rn ".... �x - b^ - v*. _ »,...� ,. ....., n. ..... _.,........ r-•-r.! dry`^•.-."'........ ". .. _ - _ j Commonwealth.of Massachusetts uk4s * ,rt cr • l �.r �.' q .W.s.t tle5f�## cd�� ec#�� � r � ,...i ..� . , Subsurface Sswage Disposal System Fonm=N:ot for Voluntary Assessments qtr G , Property Address LG 2ctf Owner _ Owner's Name . . .'' information Is. required for iN-fi pov d p/B16' `/o'2?--ra every page. Cltylrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A,.B, C,D, or.E chedked -inspection Summary D (System Failure Criteria Applicable to All.Systems)completed . System Information- Estimated depth to high groundwater 2-Sketch of Sewage Disposal System either drawn on page 15 or attached In separate file 1 II I - i t t5ins•09/08 1 Title 5 Official tnspectlon Farm:Subsurface Sewage Disposal System•Pepe 17 of 17 z J 0 o Q � CLoCL . Z C iLZ 4� •i>'�¢ ,�le t Y s < �' "h 1Y. ( i (' {,.� {,gyp, . 1•t ',- M1•'I<b'it•��NJ 11�a� / _ r<a t Y + I r + �, rl • r r:sc rJ i I C\ f.�i' 7fr'tirY ' F 1 jE1 �r a ;:.i, i a d bggl Nex° 3 • 1 3 SV� 3 r ...... ! r , N83 C 5 t i I ej +s J;t� � z -::, ria• j� �;, r..sL-�!'�r}x 4kr a{ /j - `.fr. R sY 4. Y: .•��-.��.._'. __.-i �„'+`..�G.•.��1.•�a+r�'�. .. .. _ ..�� � '''C,� _'ate+++><'` _�.,•�V •,.--_,__ _. ... - - ceAx'}'r 4�'jr++• to IL 7 � s 5 f f I 'ip 0 Lo la p ilt �,•3:� ,••t• •� h ' y�' ( .tt � I3 r ,I t4''•'•'-� ,ti yf, 9 br , n... ! '. ' � r ro 1 V! r. i f i •, 1 , ' t ..t7a xj,+ -{.1i '� I f.. L ,''). ♦ i F fi I�i dlr+3 ZY 6rr�}> ' { �i- r �t�S�e;.P. ? r!'.,F':t.+ j1,. . � •� ti a �_,. t 13 Mkt +�• t i T j� Pi frX Sltrf � J.7 rp.t� i , t + �• t r• i >< tirt .5 <3 X14,'171 4 ri ._ pf�44�J,�'3 fT` f lr rt1 rr:����i 1 S•?',tr" •S' '. w s 'rkh . .e.• 5) r�� 5 f 1t ,. ..rt ac h •r.s it � O s ' Y ✓�w .tis r r oER �` ,t, � f ..�v+y 'syr-', r •'�. 3 �- �n �a�'y4�Ni._.y � I i; � f 5 e�' r � ,F: c.�•.� i3 t #f'�y rrr 1 - a 'j�?fxE ���r a f e+i r,� : i � . "0 , { ELEVA TIONS DESIGN AS-BUILT / INV. OF PIPE OUT OF HOUSE 125.00 BURIED INV. OF PIPE AT SEPTIC TANK INLET 123.25 123.42 INV. OF PIPE AT SEPTIC TANK OUTLET 123.00 123.24 INV. OF PIPE AT D-BOX INLET 120.61 120.72 SSS / 15' INV. OF PIPE AT D-BOX OUTLET 120.44 120.54 G _ G / P / VENT 13' ido INV. AT END OF DISTRIBUTION PIPE 1 120.00 120.00 INV. AT END OF DISTRIBUTION PIPE 2 120.00 120.01 SINV. AT END OF DISTRIBUTION PIPE 3 120.00 119.99 TP PT TP-6- 1 n r of TP TP-6-2 ® FLIP N PERC 6-2 TP '�� ,;, � � ` ^ANSEN y N . 28895 " TP 96-6-2 77, E \ 39' 5, 50 ' �O, EXISTING FND. NOTE. THIS PLAN /S NOT A WARRANTY OF THE SYSTEM. IT IS TOP FND. A RECORD OF THE LOCATIONS OF THE EXISTING STRUCTURES. = 133.72' INTERIM AS-BUILT PLAN OF D-BOX 1500 GALLON �(�® ��S���A P+E DIS®O"+ ! AL S%f .-,) \ SEPTIC TANK - Lo 6- J f � \ / � AT _ 66.8 _ _ - LOT 6A, EVERGREEN ES TA TES IN NGRTI-1 AND®VER, AMASS LOT 6A PREPARED FOR: N/F COMMONWEALTH AREA 1.05 ACRES SRETT LAZf9 R OF MASSACHUSETTS SCALE: 1" = 2`0' DATE: 7/28/97, REV.: 8/11/97 Ce-I R/S Teff NJ EN h SERGI. PROFESSIONAL LAND SURVEYORS ERS LOT 5A 160 SUMMER ST. HAVERHILL, MA 01830 TEL. 508-373-0310 c0 1997 BY CHRISTIANSEN & SERGI INC. DRAWING N0. 94036042 Town of North Andover, Massachusetts Form No. 1 NORTH • BOARD OF HEALTH 20�tS LED b6 1 1� 3h� OL 19 APPLICATION FOR SITE TESTING/INSPECTION A ED �9SSACHUSE��y N Applicant &.J& 1i � NAME ADDRESS TELEPHONE Site Location �.OT Ldp 0&'U� Engineer S QA') NAME ADDRESS a / TELEPHONE Test/Inspection Date and Time -JL��3,���`f��,/���.. r/ CHAIRMAN,BOARD OF HEALTH/J Fee—/ Test No. 6 q S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town.of,North Andover, Massachusetts Farm No. 1 NORTH . y RD OF HE/ �j�ED b� �L 1, t" +$ a2°� r> ,•a/..�. +..�s' �O 19 'f cl 0 � ' °R °° APPLICATION FOR SITE TESTING/INSPECTION ADRATED PPp`'�c y �9SSACHUSE� Applicant NAME ADDRESS TELEPHONE Site Location r Engineer � 1�'�� �� 1 C) %v�.•c1E� k 1� �� CA NAME ADDRESS J TELEPHONE Test/Inspection Date and Time V n. '- CHAIRMAN,BOARD OF HEALTH 1 j Fee ' ' L"; Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. I FORM 4 - SYSTEM PUN9NG RECO Commonwealth of Massa u /Vo. %,,o/Qv�Massachu ett�UN a9 2010 . S stens �'um in Rec 1' NOFNORTH ANDOVER �yste n wrier ystem j c,r I' C� `nAry►eri �ACo Lj C 6- Y Se-4- Type: QType: Emergency ❑ Routine Cessp( •,)I: No ❑ Yes ❑ Septic Tan}:: No ❑ Yes � — Date c Pumping: L�—�a JlU Quantity Pumped: _ gallons jBOR.ACZEWS- Permit S\•ster.: Pumped by (Company): - Conte .ts transferred to: Cont: .)ts disposed at: �GL Lv Yet n C P - Da22 0 Pumper Sienarure 6rol Condition of-system/other comments: O DE?APPROVED Mksi • 1:r0719S q Insurance'Adjustment Service, Inc. 435 King St. Littleton, MA 01460 (978) 952-6966 Fax (978) 952-2459 UNDER M^ ' VERAL LAWS CHAPTER 139 SECTION 3B t V " ` Date: July 15, 2004 TO: Board of Health Town of N Ando. N Andover, MA 0,� RECEIVED RE: Insured: Brett&Deborah Lazar JUL 19 2004 TOWN OF NORTH ANDOVER Property Address: 126 Pheasant Brook Rd. WEALTH MPARTMENT N. Andover, MA 01845 Date of Loss: 7/1/2004 Policy Number: HMA0074142 Type of Loss: Water-Rot File or Claim Number: 16488 Claim has been made involving loss, damage or destruction of the above captioned property,which may either exceed$1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6,to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you fo our cooperation. Ve s; Mi a atrisso Adjust r Ext. 11 ' No......................... >±ns..:........................... THE COMMONWEALTH OF MASSACHUSETTS E30A RD OF HEALTH 1 0V)0.............OF....JV.JR.T14....../1.1`I..Oo.1/.E.-�-�.........---- Atiltfirtltitiit flit• R1114101111l Vi1010 (R111111tr trthilt f rtilli# Application is hereby made for a Permit to Construct (x) or Repair ( ) all IndividlMl Sewage Disposal System at: Lc)T— (0P11t144_Sf A .................................... :............. ..... . Location Address • or Lot No- �1s .i�✓1�.._./X<U c�f'M ........ ...y .... 3�'Xria....:M9o/g2/ Address ................................................ ....•---.........._........•................._... ........._...._................._.......-... ._.........._........................•............... Tnslaller Address Type of Building Size Lot.AdS..ft ....Sq. feet Dwelling— No. of fledrootns.......................................... .Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building :........................... No. of persons............................ ( ) — Cafeteria ( ) .. 5howerc .4 Other fixtures ...... ........................:.... ............ Design Flow.............S... gallons per person �)er day. Total daily flow........_•-. h- -------•---.._......-gallons. Septic Tank— Ligllicl cnpacityi� ..g;111ons Lengtl✓.Q...I'r........ l�'idth��_�. .°.._. Diameter................. Disposal =--re,,.;;-- :;.. . L�.L43.... Width....fS�......- Total Length.......���..._. Total leaching area..10.0........sq. ft. Seepage Pit No........ ............ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( 14 Dosing tank ( ) aPercolation Test Results Performed by.._.. 0'4?^!N LC�.................... Date... H Test Pit No. I....4.......IitintitlS per inch Depth of Test Pit.....NZ.b------ Depth to ground water........fir......... t2. Test Pit No. 2.....3.......minutes per incl.t. Depth of Test,Pit.....(.t.t__...... Depth to ground water...... -.......... i Ind ...................................................... ..........O Description of Soil......V",f..i�U1WVf... ...1 ....snlwa`I. GoM►4 ... ................... U ...................................................................... ............................•-----....._....................................---------------.............._.............-----.... VNature of Repairs or Alterations ' Answer when applicable................................................................................................ ........................................................................................................................................................................----------•--------••--.... .. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LE 5 of the State Sarlit;try Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sigticcl..................•--..........----.......------------......-------------•-•----...... ..........................•••... Application Approved 13Y................................................... Dale -------------••••--•--•---...............•-••-- ........................................ Date Application Disapproved for the following reasons:.......................................................... ................................... .-•..................................••--------•----................••---•--•----•-••..._...--•--...-•-._...-•••••-•----••--------------.......-------- ------..----........ ... Date PermitNo......................................................... Issued.................. ...._.. Date J THE COMMONWEALTH OF MASSACHUSETTS 130AR0 OF HEALTh ..........................................OF C�px•#ifirFt#p of (Itnllt �litillr>p THIS IS TO CPRI'MY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...............•-•---.............---.....--•-•-..............•-- Instal�er at..................................................... ......................................... ............................................... --------.....--------•-.................------... ... has been installed in accordance with the pro isimis of TITLE 5 of The State Sanitary Code as described in the application-for Disposal Works Construction Perinit No......................................... dated................................................ THE'ISSUANCE OF TILS CERTIFICATE St4ALL NOT BE CONSTRUEb AS A GUARANTEE THAT THE SYSTM WILL FUNCTION SATISFACTORY, DATE........................................ ........................................ Itispector............:........................................ .............................. THE COMMONWEALTH OF MASSACHUSETTS 13OAR0 OF HEALTH ...................................... ... ................................................................................. No................. O FFsE.................... �i�1>�1sls�tti �►�it�t•I�� C��ttt�#1•itr#i�l1t �i�l�itti# .... Permission is he reby granted......................:..............................r---•--..........-•••-••---•............-•-•-........-•----•................_.......-••-.... to Construct ( ) or Repair ( ) an Individlial Sewage Disposal System at No............. :.. street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ..............................................................................................•.......... itnatd of health FORM 1235 1408139 & WARREN. INC.. PUBLISHERS No......................... ns....................:......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .�111ftiirttthol flit R111111111d R111rjtN (911illifturtilltt Throat Application is hereby made for a Pern►it to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: .............................................................................. ...-...............-.-• - Location_Address or Lot No. .A.FFs5_r.'!A....1�Sva-c�4W Z-5.J�=•---("P-XD........ .....4..EIR4 -.p�►1Vi)..._ ',....r ..'_X i : t9o/'iz/ O�rner Address ................................................. tnslaller Andrus Type of Building Size Lot../rd 5..A .t._-_Sq. feet Dwelling No. of Bedrooms...........t.............................Expitisinn Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of pt"'rsons............................ Showers ( ) — Cafeteria ( ) �r Other fixtures ...:.. ........ ..........:__.................... Design Flow.............. 2 t gallrnts per person per day. Total daily flow.......... .......................gallons. Septic Tank— f_icluid capacity. ..g'111olls Lengtl✓.Q.W........ - "'icitb.C. .Y...... Diameter................ Disposal E_W.... Width....�S(....._-- Total Len th.......�4. -.-- Depth:s.��5 _ Total Icaclli►ig arc�1.../0.0-------.sq. ft. 3 Seepage Pit No........ ....'....... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( if Dosing tank ( ) aPercolation Test Results Performed by......_b(W Ie4...Q.C?.,vNL................. ... Date... Test Pit No. 1....4.......ininutes per hich Depth of Test Pit...../.OV----- Depth to ground water...... �............ G • b dGl r c, Test Pit No. 2..... ........nlmutes per ulcl.t. Depth of Test,Pit..... ...... Depth to ground water............_........... f4 .............•-•-........................_............---••-------••-•----•---.....-----•.................................................................... O Description of Soil......WFq f...Um.t k.n'..Y....f--�IN�.... 13 • U ........................................................................................................................................................................................................ V Nature of Repairs or Alterations— Answer when applicable............................................................................................... ...............................................................................................................................•---...........................------•--............-----................ Agreement The tmdersigrled agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLr; 5 of the Slate Sanitary Code -- The undersigned fru tiler agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Siglted.............................•-----.._...-----•--------=---....---._..........._..--.. ................................ rate ApplicationApproved 1)y........................................... ............................................. ........................................ rate Application Disapproved for the fo!lotving reasolls:........... .................................................•------- --------...---...---........_......-•-••-. ....................••-...._...----•---•---•. Date PermitNo......................................................... tssued.................................................. • � bate THE COMMONWEALTH OF MASSACHUSETTS BOARL) OF Hr=ALTf4 ..........................................OF._.__...................I..................I................................ Ortfiiirtite of 01toitltiittitre.. T HU LS TO ChRTITY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............................................................................•----•--••-•--_.. Installer at.........................................................:.•--------......_..._._._..._........--------------------....................._.._..............._.....-•--------......_....--- has been installed in accnrdance with the provisicins of TITLE 5 of The State Sanitary Code as described in the application-fnr Disposal Works Construction Permit No......................................... dated................................................ TNE•ISSUANCE OF TMs CERTIFICATE MALL NOT IIE CONSTaUEb AS A GUARANTEE MAT TNS SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................................._.................._.. ....... Irlspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF..........................................................................._...... No......................... ... FEE........................ B1111toliai 11011da" 0g1titutritrtittii jlrriitif Permissiortis hereby granted.........:..........:..............................r...........----......---...._..........._..._......_......--•.............................. to Construct ( ) or Rep it ( ) an Individual Sewage Disposal System at No..... :. Strcct as shown on the''application for Disposal Wotl<s Construction Permit No..................... Dated.......................................... •-----------•---•.............................................................................•----...--- DATEIloard of Ifea11L .......-•---......--•-•---•............................ FORM 1235 M013139 & WAnnEN. INC.. PUSLISfftnS i �1 I PHEASANT BROOK 9 q � ROAD I ti I 30.91 21.09 EX/STING I LOT 7FND. •� ro�:.Issr Z=128•� l � I / L = 23.5' O• LOT 6A LOT 5A FOUNDA TION LOCA TION PLAN ;,,�I, �'"���OF W E i 70 APPLICABLE ZONING BY-LAWS M UMT WHEN COALSTRUCTED. (THIS CERTMC4710N DOES NOT CONSIDER ANY OTHER RE57AICIMM SUCH AS COYEMAK 3: WETLANDS.EASEAf M$, CLIENT: J. V.CAGGIANO & SONS.,INC. O of M E>C.) IRIS DRAWING SHALL-NOT HE USED BY THE CLIENT FOR ANY THIS CERTIFICATION /S MADE AND LIMITED PUCE 0771ER IRAN 7MT OUTLNED ABOW D(CU T WITH THE WR11M PERMISSION OF CHRISTUNSEN t SERB Mr- TO THE ABOVE CLIENT. FURTHERMORE THIS DRAWING IS THE COPYRISHM PROPERTY OF CHRS7pNSEN R SERGI INC. AND ANY UNAUTHORIZED USE /S PROMMMCHR/SIMNSIN R SERC/ TAKES NO RESPWWRILl7Y FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY IMOk- M4n0N CONTAINED HEREM LOCATION.-LOT 6A "EVERGREEN ESTATES" NORTH ANDOVER,MA. OF Mq SCALE: 1"=80' DAME.- 4/11/97 CHRISTIANSEN &SERGI ' � IM SUMMER ST. HAMWUL,MA. 01MO IML. M-373-010 - ®1887 BY CHRLSTUNSEN ! SM /NG DWG.NO.: 94036076 FORM. 11 - SOIL. EVAL.UAT:OIt FORM Page 2 of 3- Locatiorr<Address-orLot No: LOT _ i • On=sate Kevil w— HolembeDate:. /T: CWeather,' .". . Location (identify on site plan) Land Use Slope.(%) 8./�a. Surfac&Stones MN`s SS71w + vK - '. Vegetation•:.QKr.. WN�TYZ: 1°Inr �..H;�CfCoILY�.,:Gbtlal= GL� .::.�taw } Landform ... _. ..... Position on.landscape-(sketch on the back) Distances=from: Open Water Body� :.w feet Drainageay, feet i - E Possible=Wet Area..... feet' Property Line. feet Drinking.Water Well. .._.... feet Other: _ :.:.::...:::...:.:..:. DEER OBSERVATION H•O:LE. LO"( .. De th^frons. Soil-Horizon._ Soil Texture, SoiF:Coloc Soil• Other Surface�(Inches►: (USDA) (Munsell- Mottlings lStmcuue;Stones;Boulders�.Consistency,. Gravel), r; 1y04N..y recjorC. . I I 3G 13w- Vr3 fs G. f o�I1 4/(a �►r�sSi u , a+ , M Y9v4 a0 7— 5;y�ro�3.F /h;�tSS�uE: r�izrr�et,E°1b ���_ fo (Z Val 1-S�. 7WE C iu�415 30°, aoH4� r Z . s s 1 l IL C)OM To Parent Materiab(geologic) Tf LL. DepthtoSedmck:T//Z hr Groundwater:- H Weeping from Pit Face De t to Grou d ales• Standing Water the ole: P 9 o g ``. Estimated.Seasonal:High:Ground.Water: DFFAPPROVM FORM=12107/95'. �lO�A4NRela�D.R'IFoeSS ■a 4ei la ■ + .. '' � . FORM 11 _ SOIL EVALUATOR FORM Page 1 of 3 ert r. F Date: No. Commonwealth- of Massachusetts ' Nps �Naou Massachusetts oil uitabili Asse merit or n-site ewa Disposal S a. Date: -/-7 l9� Performed By: ..:...t�WN�E✓4......0. ^' c. ....................................... S r�Nl� ................................................................................................................. Witnessed.By: .......... . ......... .. ......STP.I�1 ...................................... . _ Gym �C I pwnet's Naas ME�I/�/p peVl:1Np/ya.+/' ��. i lmtiat Ad"*=.Or � I 1 e—UEPI �`� Addtat.ted' •i t;ST-P�l�f rdepnaic/ 44 GIZEJgT PON 4) 091 VIE ; . ew Construction Oz- Repair Q ;.A .V Office,Review Published Soil Survey Available: No Q Yes. i S 8 • Scale � • .........�......... Soil Map Unit Cr .................. �.. Year Published 1`f :�..... Publication. d 61r S7aN6S .................:........... r W�(,E. t)R&N�.: Soil Limitations ............................ .....4. 'TlJ...... ........::...... Drainage:Class a Surficial.Geologic ReporrAvailable:No Q� Yes Yeas Published Publication Scale Unit .................................................... Geologic.Material (Map ) ................ ............................................ Landform .................................................. ; .. Flood Insurance Rate MaP: El Q� boundary No - 0 year flood b ary Above 50 y Within 500 year flood boundary No QYes Within 100 year flood boundary No QYes. Q r. Wetland Area: ...................................................................... :.. . National Wetland Inventory Mag(map unit) r ...................................... Wetlands Conservancy Program Map-(map.unit). ............................................................ 't Current Water.Resource:Conditions (USGS): Monttr - Range:Above Normal QNormal QBelc^i Nexmal Q. other References: Reviewed: jR DEF AppROVED FORM•12/07/95' r. FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 i. Location Address or Lot No.. WT 6 EVEt2G1"EA1 F, J p-ffj Determination for Seasonal High Water Table Method Used: I ❑ Depth observed standing.in observation hole................... inches ❑ Depth weeping from side of observation hole............ inches Depth to soil mottles ....: :: inches t Ground water adjustment................... feet- Index eetIndex Well Number .................. Reading:.Date. ................... Index well level ................... e t F. Adjustment factor ................... Adjusted:ground water .level ........................................................ 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? YES If'not, what is the depth of--naturally occurring pervious- material?' r; E Certification i 'E I certify that on 10 (date) I have passed the soil evaluator examination approved by the Depattment of Environmental Protection and thatthe above analysis., was performed by me-consistent-with the-required training, expertise and experience t described in 310 CMR 15.017. i Signature Date 3a 6 E i E } r DEP APPROVED FORM-12107/95 E 'r r ' FORM 11 - SOIL EVALUATOR FORINT Page Z of 3 Location Address.or Lot No. On-site Review n Weather g6' — 7 . Time::.. ..:.% 5� Deep Hole-Number .::.::.:b•:.,Z . ... Date:-... ::...,... Location (identify on site-plan) ::::...::::: ...,v:.:::.::. .:...:.. .:::...,.:::..,::::.::::::::.,::;:.::.:,:::-_:.. ,::.,:«..:.:.r.. .:::.:.-...,:...: ..:.::..:..:....._:....:.. . 4`vauaF�•. Surface Stones. Land-Use------t�J�Uo.t�.:�..:...:. Slope(%) .8 ' ftp Vegetationw.14-( Landform .::::.:...:.::.. :: . . ....:.... .._:.:.: .................. .... .:.......,.. . .......... ..... . .. .. Position on landscape(sketch on the back) ............ Distances from: , Open Water Body feet Drainage;way. feet Possible-Wet Area... .:. feet' Property Line ....3 U. .. feet Drinking Water Well :.:..:..:.: . . feet Other. ...:.....:..:.....:::,:....:.::::.... DEFT CIEtSMVATIQM HOLE-C.G~ Depth fronr S'oil.Horizorr Soil Texture= Soil Color Soil. Other. Surfacar(lnches)• (USDA► (Munsail) Mottling: (structure Stones;,-Golders,-Consistency, 0/(r U r l FSL. lay 31Z G N l•4—w-u Fere M��:� �c►or-sti 3f. i3u 104P—If/a MpN�� 2oa�'s- � '(or3 /►tIFSStI/ l Ff?.1 fie.its• C, WIF5L ZSYSI¢ 14-4 p,5 8 50 °,(: QoNo1 Zo s -S LUIS to 0/0' G 4ec f . 1h . °/�: Parent•Material.(geologic) T(LL DeptM°8edrock: 0 DeptfrtoGroundwater, Standing Waterinthe•Hole: Weeping,from Pit Face: Estanated Seasonab High-Ground:Water: z DBPAPPROVED FORM-12/07195 FORM 12 - PERCOLATION TEST Location Address or Lot No. LOT- U�/LGfZfi �y 5Ti4-iS COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test* Date: Time Observation Hole #. Penz 61— hftic �- Z Depth of Perc 74 Start Pre-soak 71 10 "o(o End Pre-soak K) ` L Time at 12" Time at 9" L ;S"Z Time at 6" Z 3Z Time (9"-6") /C1 '7 Rate Min./Inch J Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed L7 Site Failed ❑. ............_.......................................................................................................................`....._....... Performed By: )I ON16L O C�QN/►/�(,� Witnessed By: S A NVY S/-wit Comments: DEP APPROV®FORM-IV07/95 PLAN REVIEW CHECKLIST ADDRESS I—Ile, '25V-0 C ENGINEER GENERAL 3 COPIES L� STAMP C""' LOCUS L'' NORTH ARROW (� SCALE CONTOURS PROFILE 6- SECTION C/ BENCHMARK, SOIL & PERCS t/ ELEVATIONS WETS. DISCLAIMER L--------WELLS & WETS WATERSHED? DRIVEWAY Elev) WATER LINE //� FDN DRAIN SCH40 TESTS CURRENT? SOIL EVAL c OZ-50Q SEPTIC TANK/ MIN 150OG . 17 INVERT DROP v GARB. GRINDERZ(2 comps +200) 25 ' TO FDN l/ MANHOLE ELEV GW ## COMPS. l GB D-BOX SIZE ## LINES FIRST 2 ' LEVEL STATEMENT INLET - OUTLET (2" OR . 17 FT) TEE REQ'D? LEACHING / MIN 660 GPD? y/RESERVE AREAy 4 ' FROM PRIMARY? �2% SLOPE 100 ' TO WETLANDS1---"- 100 ' TO WELLS 4 ' TO S.H.GW (5 ' >2M/IN) 35 ' TO FND & INTRCPTR DRAINS L/ 400 ' TO SURFACE H2O SUPP G� 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (15 ' ) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 611/100 , ) L-' SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MIN. 4" PEA.,STONE?' VENT? (>3 ' COVER; LINES >501 ) BOT + SIDE X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright D 1995 by S.L. Starr PITS MIN 660 LEACHING MIN 1 (13 'x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC .2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x ##) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60 ' X 601 ) MIN 13 ' X 16 ' PIT BOT + SIDE X LOAD = TOTAL (L x W x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS / MIN 660 GPD 900 ft2 BED if GW MIN 4 ' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? —1 4" PEA' STONE? Q---DIST LINE SLOPE .005? >31COVER-VENT .�// SCH 40 V MIN 12" COVER- -- RATE / LDG 'ems X 660 = NO X 16 = TOTALA66�/ 241:50 G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY 9Pm L W D Vol . DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME 9Pm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1 ' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? Copyright 0 1995 by S.L. Starr Hf;A4S4T BROOK ROAD � I .s ,3 1 . 2 ' .30. 9 ' 27so EX/ST/NG I� FNDw 4010 Act 14 l L = 23. 5 ' , 1�• Ole OD LOT 5A 9 PH SANT BROOK ROAM � _ L,16 A; , I 30. s D 27 , 0 EX/5T/NG � FNDO s 12.& Ca FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone LOCATION: Assessor' s Map Number Parcel Subdivision 6_0,e4 Cl-e-eu IL 5 f-A-re s ' Lot(s) 40,1,9 Street Li f 69 St. Number ************************Official Use Only************************ RE 901414- DATIONS OF T WN AGENTS: �` �✓ �, %/�� Date Approved Mservation Administrator Date Rejected Comments Date Approved VI;Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire. Department Received by Building Inspector Date CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 August 30, 1996 TOWN OF NORTH ANDOVER/ BOARD OF HEALTH Ms . Sandra Starr North Andover Board of Health 146 Main Street `AUG 3 0 19% No. Andover, MA 01845 RE: Lot 6, Evergreen Estates - Dear Sandy: Attached are NEW plans for the Septic System Design at Lot 6, Evergreen Estates . Ver ; truly your , f o�iU Philip G. Christiansen PGC;lc I I 1 i SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan V REVISED PLANS: YES $25.00/Plan DATE: �`f 3d Cl DESIGN ENGINEER: S When the submission is all in place, route to the Health Secretary j I r^ 73, YS { ,2 a 2 JUL-02-1997 09:23 J.MASTERSON CONST. CORP. P.03 sem. - �: .. . .... .. ,. SU��1rB'T, Il�C. 9 THOMPSON'S POINT T CHARLTON STREET POM AND,W 04102 EVP.RIS1`T,MA 02149 (20'n 879.6000 (617)389 3700 CONS1RUMON MATERIAL QUAMY CONTROL �. TESTING SERVICES REPORT OF MADATION . . PROJECT NO.: — REPORT DATE: AT 7 PROJECTNANW: S Te-A00441 "o= 7''• CLIENT: op A.s. PVA. C4090 SAMPLE NO.: A09 SAMPLE BY. Q A er.v y DATE SAwLm: X7 T; v* SAMPLEMENTMCAnON: SIEVE PERCENT SPECIFtCATION REQUDtE WM SITS PASMG A B C D 4" 3" 2-5- 2" 1.5" �Lw . 1" 314 oo 1rr yrs„ U4" #4 98 010 016 #20 #3a la 040 G #SO 215 #6a Q 0100 #200 :2 0 Iee& tads mode fads meas Ss�s mep A. B. C: D: COQ: e.0 4p er Zr TESTED BY: AW A. ,oy wr&AREVmWED BY: DON WALDEN laaes�ss dog Revink 4/181% S'1NClIt1�0ti� � TOTAL P-02 TOTAL P.03 r 3� k r i t (a) The retaining wall shall be constructed of reinforced concrete, shall have no '# s { V. and shall be waterproof. (b) The retaining wall shall be designed by a Registered Professional Engmeer {t hti t - =gha certify that the above condition is met by the submitted design. �; � r } (c) The upgradient side of the retaining wall shall be waterproofed. q � V. � s•' t � w, { (d) Construction of the retaining wall shall be supervised by the design engineer. x"` t (e) An as-built plan shall be prepared and certified by the design engineer that the " K been constructed in accordance with his approved design plan. , � =a ` w`t` ` 9 (f) The elevation of the top of the retaining wall shall be no lower than the "br devation,which is the elevation of the top of the two inch layer of 1/6 inch to �/2 inch #t r ` ? stone aggregate cover. ,. ` ,4W. '; z(g) The distance from the wall to the edge of the leaching area should be at least ten feet ` z? F .( ) FiU material for systems constructed in fill shall consist of select on-site or imported soil g X, � dy �' material. The fill shall be comprised of clean granular sand, free from organic matter and ?� deleterious substances. Mixtures and layers of different classes of soil shall not be used. The fill shall not contain any material larger than two inches.A sieve analysis,using a 94 sieve,shall t t be performed on a representative sample of the fill.Up to 45%by weight of the fill sample may � + be retained on the#4 sieve. Sieve analyses also shall be performed on the fraction of the fill a ,ate sample passing the#4 sieve,such analyses must demonstrate that the material meets each of the , > ' following specifications: SIEVE SIZE EFFECTIVE %THAT MUST PARTICLE SIZE PASS SIEVE # 4 4:75 mm 100% 450 0.30 mm 10%_ 100% 4100 0.15 mm 0%- 20% j #200 0.075 mm 0%_ 5% A plot of the sieve analyses of the portion of the sample passing the 94 sieve shall fall on or between the lines on the following graph: PARTICLE SIZE DISTRIBUTION. TO #200 1100 fs0 A" A b h, � 1R �11 g f4 Sieve Sze r I e- 80 It f 11i ,� I II 70 Z t WT ! I I I 6" 1, CT 60 a� W 50 r w ao ! lF I I G.a ll J-- U a= IL 30 n � 4 20 I I 10 Micron 60 200 600 2 6 10 mm 12/1/95 (Effective 11/3/95)-corrected 310 Ova- 531 I ELEVATIONS DESIGN AS—BUILT INV. OF PIPE OUT OF HOUSE 125.00 XXX JUL 2 9 1997 INV. OF PIPE AT SEPTIC TANK INLET 123.25 123.42 INV. OF PIPE AT SEPTIC TANK OUTLET 123.00 123.24 INV. OF PIPE AT D—BOX INLET 120.61 120.68 15.009 INV. OF PIPE AT D—BOX OUTLET 120.44 120.51 INV. AT END OF DISTRIBUTION PIPE 1 120.00 120.01 h � e INV. AT END OF DISTRIBUTION PIPE 2 120.00 120.01 VENT INV. AT END OF DISTRIBUTION PIPE 3 120.00 120.01 - TP PTP rk TP-6-2 s „ r LOT 6A AREA = 1.05 ACRES 740T 0' O b;b ♦ f r "j NOTE: THIS PLAN /S NOT A WARRANTY OF THE SYSTEM. IT IS / A RECORD OF THE LOCATIONS OF THE EX/STING STRUCTURES. INTERIM AS-BUILT PLAN OF D-BOX SUBSURFACE DISPOSAL SYSTEM AT 47' 1500 G LLON - SEPTIC TAN 66.79' LOT 6A, EVERV BEEN ESTA TES 51' EXISTING I N S FND. NORTH A NDO VER, MASS T.0.F.=133.7' PREPARED FOR: BRETT LAZAR SCALE. 1" = 20' DATE: 7/28/97 NAL LOT 5 CHRIS T I A NSEN 'xPRO SERGI PROFLAND OSURVEYORSEERS PLAN160 SUMMER ST. HAVERHILL, MA 01830 TEL. 508-373-0310 SCALE: 1 = 20' c0 1997 BY CHRISTIANSEN & SERGI INC. DRAWING NO. 94036042 MAP AND PARCEL ADDRESS OWNER SIZE OF LOT IN SQUARE FEET l g b Sq F*, #BEDROOMS SEPTIC SYSTEM LOCATION (For example,FRONT YARD SOUTHEAST CORNER) FINAL GRADING DATE Lf AS BUILT PLAN IN FILE? ..0 INSTALLER DWC PERMIT DATE CERTIFICATE OF COMPLIANCE DATE ENGINEER I I r s APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: ;' CURRENT INSTALLER'S LICENSE# LOCATION: ZeT LICENSED INST LER: SIGNATURE: TELEPHONE# 3—G 5-f- S'G CHECK ONE: REPAIR: NEW CONSTRUCTION: IF,NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No .� - Foundation As-Built. Yes No Approval Date: Town of North Andover, Massachusetts F°""No.s BOARD OF HEALTH I NORTH Of .� c r^,tiO off- 19 L A • F A , a t ..... `� DISPOSAL WORKS CONSTRUCTION PERMIT ,3., CHUSEt Applicant NAME ADDRESS TELEPHONE Site Location j �-{ n 1 0L1,� i� Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. .tt R AN BO RD OF HEALTH Fee D.W.C. No. oZ i f Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH August 14 97 97 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired ( ) by R0 be,r S 1 ombo INSTALLER at T.ot- #6 FVar[TrP_Pn FStatac North Anc3nvar , MA 01845 has been Installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 861 dated g/30� 19 96 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. cc: -Building Dent. I ELEVA TIONS DESIGN AS-BUILT i INV. OF PIPE OUT G." HOUSE 125.00 XXX INV. OF PIPE AT SEPTIC TANK INLET 123.25 123.42 INV. OF PIPE AT SEPTIC TANK OUTLET 123.00 123.14 i INV. OF PIPE AT D-BOX INLET 120.61 120.68 I 15. 0• INV. OF PIPE AT D-BOX OUTLET 120.44 120.51 INV. AT END OF DISTRIBUTION P/PE 1 120.00 120.01 _. WIT !NV_ AT END OF DISTRIBUTION PIPE 2 120.00 120.01 ' (1 INV. AT END OF DISTRIBUTION PIPE 3 120.00 120.01 TP p NTP-6-1 TP i - TP-6-2 LOT 6A 740' AREA = 1.05 ACRES �D At tom' 5p rye/ NOTE: THIS PLAN IS NOTA WARRANTY OF THE SYSTEM. IT IS � A RECORD OF THE LOCATIONS OF THE EXIST/NG STRUCTURES. INTERIM AS-BUILT PLAN D-BOX �,rs) OF f SUBSURFACE DISPOSAL SYSTEM 47' / AT 1500 GALLON \ SEPTIC TAN 66.79• i LOT 6A, EVERGREEN ESTATES 51' /N EXISTING FND. NORTH ANDOVER, MASS T.O.F.=133.7' PREPARED FOR: BRETT LAZAR SCALE: 1" = 20' DATE: 7/28/97 PLANLOT 5 CHRISTIANSEN ;X, SERGI PROL.ANDIONAL SURVEYORSEfRS 160 SUMMER ST. HAVERHILL, MA 01830 TEL.508-373-0310 SCALE: 1" = 20' ©1997 BY CHRISTIANSEN & SERGE INC. is DRAW/NG NO. 94036042 N®RTjy Town of over No. . . °'9A_C dover, Mass., >A21 19 AX / +� w OCMIC NE WICK M1L�'�• i • '9 °q�E o�Pa� �� S E BOARD OF HEALTH PERMIT T Food/Kitchen i Septic System I BUILDING INSPECTOR THIS CERTIFIES THAT : �.li� _.Y�- ..� •....�..................................................... ..< Fojindation has permission to erect....................... g ,.: ` f lam_ Rou p ................. buildings on ........ ./..�:_.t,... r�'f� .a�Jj:..�... �.....-.........:...%_v f tobeoccupied as....................................................... ........ . ...ff.`:!..�.:/�'........................................ Chimney ` ` provided that the person accepting this permit shall in every respect conform to the terms/of the application on file in Final i this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of in the Town. of North Andover. PLUMBING INSPECTOR !,VIOLA ON of the Zoning or Building Regulations Voids this Permit. r p !•_"eta �,�.,, � �R PERMIT EXPIRES IN 6 MONTHS LE C SP UNLESS CONSTRUCTION STARTSL10001 ;�7 ........... : .. ..... '%$UtLDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR in a Conspicuous- Place on the Premises — Do Not Remove Route Display, P � t � No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FI E DEPARTMENT` Burner street No. Smoke Det.0 I 1 FORM U - LOT RELEASE FORM (. (p OI INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT–Debbie&Brett Lazar_ `PHONE_978-682-9092 LOCATION: Assessor's Map Number -12880 10(0 �s PARCEL r SUBDIVISION LOT(S) 6A STREET Pheasant Brook Road ST. NUMBER-126— USE UMBER126USE RECO NDATIONS OF PVP AGENTS: CONSERVATION ADMINISTRA,T` R DATE APPROVED J� // DATE REJECTED COMMENTS I(%,0 . V-J IA5.'de' too TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSP CTOR-HEALTH DATE APPROVED DATE REJECTED T)e INS CTOR- AL DATE APPROVED �s D " DATE REJECTED COMMENTS / f,,z��-;.. u c :a Y®� .—cT c,e l-- > C f1 PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 91.97 jm Town of North Andover, Massachusetts Form No,z f 00RT1y BOARD OF HEALTH 1 p DESIGN APPROVAL FOR • ;.fib+��o•�•�'� ss"CHOSE( SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • ApplicantTest No. : Site Location tT � • Reference Plans and Specs.—coh . S�� • 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 l Fee ��. Site System Permit No. v ELEVA TIONS DESIGN AS-BUILT Terry,,... r• • _ f INV. OF PIPE OUT OF HOUSE 125.00 XXX JUL 2 9 1997 INV. OF PIPE AT SEPTIC TANK INLET 123.25 123.42 INV. OF PIPE AT SEPTIC TANK OUTLET 123.00 123.24 INV. OF PIPE AT D-BOX INLET 120.61 120.68 5.pp' INV. OF PIPE AT D-BOX OUTLET 120.44 120.51 Of INV. AT END OF DISTRIBUTION PIPE 1 120.00 120.01 VENT � F INV. AT END OF DISTRIBUTION PIPE 2 120.00 120.01 INV. AT END OF DISTRIBUTION PIPE 3 120.00 120.01 TP / TP-6-1 � `N p SAS P Y TP N TP-6-2 : t r: LOT 6A AREA = 1.05 ACRES 740T0' c� NOTE: THIS PLAN IS NOT A WARRANTY OF THE SYSTEM. IT IS / A RECORD OF THE LOCATIONS OF THE EX/STING STRUCTURES. INTERIM AS-BUILT PLAN OF D-BOX SUBSURFACE DISPOSAL SYSTEM AT 47.' 1500 G LLON SEPTIC TAN 66.79' / LOT 6A, EVERGREEN ESTATES 51, IN EXISTING FND. NORTH ANDOVER, MASS T.O.F.=133.7' PREPARED FOR: BRETT LAZAR SCALE: 20' DATE: 7/28/97 LOTG/ /R/S T IA NSEN �X� SERGI PROLAND/OSURVEYORSNAL EERS PLAN ' . 160 SUMMER ST. HAVERHILL, MA 01830 TEL. 508-373-0310 SCALE: 1" = 20' cQ 1997 BY CHRISTIANSEN & SERGI INC. DRA WING NO. 94036042 DelleChiaie, Pamela From: shash.syme@gmail.com Sent: Friday, June 24, 2011 11:36 AM To: DelleChiaie, Pamela Subject: Re: Well Water Testing Guidelines Thank you! ------Original Message... From:DelleChiaie,Pamela To: 'shash.syme@gmail.com' Subject:Well Water Testing Guidelines Sent:Jun 23,20113:26 PM To: Sharon Syme—978.258.8236 Re:126,Pheasant Brook Road Here is the well water testing guidelines. I have not yet received a copy of the pump sheet. You can can Boraczek directly if you need it sooner. Best Regards, Pamela DelleChiaieDepartmental Assistant I Community Development I Health DepartmentTown of North Andover1600 Osgood Street I Bldg 20 1 Suite 2-36North Andover,MA 01845 ( Office-978-688-9540 2 Fax-978-688-8476 Email-pdellechiaie@townofnorthandover.com ; Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."—Anonymous If you are happy with the customer service you have received from town departments,please let us know...feel free to com Tete the general Comment Form(link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:http://www.sec.state.ma.us/pre/preidx.htm.Please consider the environment before printing this email. Sent on the Sprint®Now Network from my B1ackBerry® r 1 DelleChiaie, Pamela Pamela From: DelleChiaie, Pamela Sent: Thursday, June 23, 20113:27 PM To: 'shash.syme@gmail.com' Subject: Well Water Testing Guidelines Attac 20110623134702023 C o: Sharon Syme-978.258.8236e:l26 Pheasant Brook Road Here is the we water testing guidelines. I have not yet received a copy of the pump sheet. You can call Boraczek directly if you need it sooner. diet�?egaada, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover,MA o1845 2 Office-978-688-9540 Fax-978-688-8476 Email-pdellechiaie(@townofnorthandover.com -2� Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous If you are happy with the customer service you have received from town departments,please let us know...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Papes/NAndoverMA WebDocs/contact 1 testing might be warranted if your water When taking any sample, DEP recom has elevated nitrite/nitrate concentra- mends that it be taken after a heavy rain- tions or significant amounts of pesticide storm.`ham events tend to highlight condi P rotes:t Your have been applied near the well. These tions of improper well construction or poor less-routine tests may not be performed soil filtration. at all state certified laboratories. Fa m i ly What the Tesft Tell You When To TestResults will reveal the level atwhichany of Test Your Well's DEP recommends that prospective the tested substances were found in your homebuyers test the water in a home water sample. The mere presence of these Water Quality Today with a private well before purchase_ contaminants in well water does not neces- Water quality in wells is generally stable, sanly imply that there is a problem. How- and owand if a change is going to occur,it occurs ever, when levels exceed state or federal slowly.Thus the interval between water health standards, you should take steps to quality tests, once you've purchased the correct the situation. Several methods 'are home,can generally be in terms of years available fromcommercial.contractorstotreat (see chart) if a well is properly con- ated water. structed and located in a safe area. However, the following conditions For More Information would prompt more frequent testing. • Heavily developed areas with land uses As private wells in Massachusetts are that handle hazardous chemicals regulated at the local level, you should -Recent well construction activities or first contact your local Board of Health for , repairs. DEP recommends taking a your town's private well testing require- bacterial test after any well repair or ments. For more information about pn-- pump or plumbing modification,but vate wells including additional water qual- only after disinfection and substan- ity testing recommendations, you should tial flushing of the water system. refer to the DEP Private Well Guuieltnes, A Guide to Water Quality • Contaminant concentrations above which are available on the Drinking Water state or federal standards found in Program's Publication web page. Other Testing for Private Wells earlier testing. information such as the listing of state in Massachusetts •Noticeable variations in quality like a certified laboratories can also be accessed water quality change after a heavy through the web page. rain, extended drought, or an unex- InnA united Stat" kilned chap a in a reviousl For additional assistar►ce contact the DEP A P g P y Drinkin WaterProat v N"SVIand trouble-free well (i.e. funny taste, g cloudy appearance, etc.). MichDement of Environmental Pn*ec mD&&hgwaterPzogtaxn 1 winter street:,6&Floor LI Boston,MA 02108 ®printed on 100%recycled paper,with a minimum of 5M. Phoma 61.7-292-5770 '•'••:,'•:`'; tMV1110 UYt MT.LL •w 407l CT10M past consumer waw,using vegetable based inks www.mass. ov de g P EPA 901-F-04-002A February 2004 Private Wells fug of lawn equipment, and disposal of household chemicals can contaminate If you have a private well, then water the ground when done improperly.Even Contaminants & Testing quality testing should be important to an on-site residential septic system can Frequency you and your family. pose a threat to your well. That is why Some contaminants in drinking water taking measures to protect your well from Siandard Analysis Testing have been linked to cancer and toxicity, contamination is so important — --I Frequency posing a risk to human health. Many Arsenic Monitor contaminants often have no taste, odor, Recommended Tests Chloride 1 initially for all or color.Their presence can only be deter- The following tests provide only the copper contaminants, mined by laboratory testingmost basic indicators of a well's water Fluoride and then at a While there is no state requirement to quality. These tests identify some of the Hardness minimum of have your well water tested (although common natural and man-made contanu- Iron once every ten there may be from your mortgage lender rants found in our state's well water. Load da years(except or local Board of Health), the Massachu- However,you should also consider nearby Manganesfor bacteria setts Department of Environmental Pro- land uses to decide whether additional PH and nitrate/ tection (DEP) recommends that all tests are appropriate for your well.It is twt ——-J nitrite which homeowners with private wells do so, necessary to do ddl of the tests at one trine. Coliform:Bacteria should be and use a stage certified laboratory. Nitratem"rite sampled ♦ Standard Analysis Radon yearly),or as This basic analysis covers the most coma- Grass Alpha Screen otherwise Contamination of contaminarft Some of these contazni cbedrodcwells aHyl requiredbythe nants pose health-related concerns, while vocs Heal Board of Wells others only affect aesthetics(taste and odor). Well water originates as rain and snow 6 Radon that then filters into the ground. As it Radon can be a well water problem in soaks through the soil, the water can Massachusetts, especially in bedrock 6 Volatile Organic dissolve materials that are present on or wells. Presently, there are no federal or Compounds NOCS) in the ground, becoming contaminated. state standards for radon in drinking The most common VOCs come from Some contaminants are naturally oc- water,only suggested action levels.[Note: gasoline compounds (such as MtBE and curring from features found in the rocks If Radon levels are elevated in your well benzene)and industrial solvents(such as and soils of Massachusetts.These include water,you should also consider checking TCE). MtBE can be found in well water substances like bacteria, radon, arsenic, your indoor radon levels.] even in remote areas. uranium, and other minerals. Other contaYninants find their way onto 4 Grow Alpha Screen the land from human activities.On a large Radioactive minerals, such as radium- ♦ Additional Tests scale, industrial/commercial activities, and uranium, may be dissolved in well Circumstances relative to your well improper waste disposal, road salting, water. A Gross Alpha Screen is a simple may require additional testing not de- and fuel spill§ can introduce hazardous test to judge whether further testing for scribed here. For instance, DEP does not substances to the ground.However,even specific radioactive minerals such as ra- recommend frequent testing for things typical residential activities, such as the dium or uranium might be needed like pesticides, herbicides, or synthetic application of fertilizers and pesticides, organic compounds, mainly because of U '� "� '�by Ae U.S. Evr�rroranenbat Protection Agency. the high cost However, such(cont. over) .. r a � ` �+il�"9'Os.•°^E'�,tS��1 w.r h'i� ..�r4-7e, 'arc + - wh x.,rr- %via 'S 1 Y ^ Private Drinking Water Wells i' . • Zf'Y. ` ��1���k.\'. �Ce 4 F„7TT000Cv l� This material is based upon work supported in_part by the Cooperative State Research;Education,and Extension Service,U.S. Department of Agriculture,under Agreement No:'MS 1130-9775.Any opinions,findings. conciusions, or recommendations expressed irr.this.publication.are:those of the author(s),and.do novrecessaMy reflect the view of the U-S Department ofA&itulturea 7 C !r•t,., to ' . . . r z f you are a real estate agent representing the buyer or the seller,you may have a question about how you can best inform your client about private well water issues during a property transaction.This brochure will help to answer your questions_ According to the US Environmental Protection Agency. (EPA), it is estimated that appro)dmately 23 million people. or 20% of New Englanders, rely on private wells for their drinking water ^` sup*This percentage increases to more than 40%for Vemxm New moire, and Matte. Contaminarrts, if present in drankhV water at elevated keels, can pose a risk to families. Many of the contaminants that can be present in a private well ane odorless, tasteless.and colorless_The only way to identify their presence is to have the well water tested. Knowledge " is Power! Advise your client to get the ! most IrikDrmatlon possible f-om �• R• '. "v' qualified professionals aboutR : ' both the well water qualityand SALE the condition and fimaioning of the endredrat[drgwat erSYS- s tem.Fortestingrecommenda- „_ tions and information about qualified<: fied professionals, it is best to contact the appropriate stats N. agency,fisted in the For More Information section at the end of this brochure. • r .. . . a What tests should be conducted? While this recommendation may vary from state to state, the FPA suggests that an initial test should include coliform bacteria,nitrates/nitrites,and pH.In addition,tete homeowner should consult with experts about the need to test for arsenic. lead,copper, radon,a gross alpha screen,and volatile organic compounds. For more information on specific testing suggestions in your state,contact the appropriate state agency. The buyer's lending institution will most likely require that the well pass a water quality test prior to loan approval. Most lenders require testing for bacteria, nitrate and lead at a minimum. Keep in mind that these testas are intended to ensure that the lender is not making a loan on a property : with a faulty system,in case they have to repossess the property- , The testing is not necessarily `. required to protect the health of the residents. .ems. Where should the samples be taken? Thewater sample should be collected from the cold water kitchen tap. Most water testing laboratories supply their own sample containers and provide detailed instructions on how to properly collect a water sample.Use the bottles provided and carefully follow all instructions to obtain a good sample.In some cases,a laboratory professional may corse to the home and collect the sample. 3 i S 4 ' been chlorinated because of a failing bacteria or other test If there is a home water treatment system a water test should Chlorine would mask the presence of bacteria and other be done on both the raw water coming into the house before contaminants that may be present in the well water.A pool the treatment system and a separate test after the water has chemical test kit can confirm whether chlorine is present If passed through the treatment system.This will identify the chlorine is present,delay the water test.Remove chlorine from contaminants that are present and ensure that the treatment the well and plumbing by running the water at each faucet until system is functioning properly_ no chlorine odor is detected.Wait at least 24 hours after no chlorine odor is detected before re-testing for the presence of Are there any specific state chlorine and collecting a water sample. using the pool chemi- test i n g requirements? cal test kit prior to sample collection will ensure the continuity of checking for chlorine each time a sample is collected. State requirements for private well testing at the time of property sale vary from state to state.It is best to check with the What are the costs for testing? state drinking water agency for requirements.In addition.your What to test far and how mutts the test will cost will b client can ask the appropriate state agency about any known vary y contamination problems'in the area to assist in determining state and lab.Testing can range from as little as $5 for an what contaminants to test for, individual test parameter(like pH)to$250 or more for a com- bination of tests covering a wide spectrum of parameters.See Where should the water be tested? the state drinking water agency contacts for more information. Your client should arrange to have the water tested at a Once the testing is done, state certified lab.These labs follow accepted procedures for - testing contaminants. Make sure that the lab is certified to test how does my client know the for the contaminants requested.The lab will provide sampling water is safe to drink? instructions and collection bottles for taking the water sample, The EPA establishes limits on the concentrations of certain or in some cases,may send a professional to the home to collect contaminants that would pose a public health threat if present the samples. Contact the appropriate state agency for a listing in elevated levels in public drinking water supplies.These limits, of certified labs_ or standards,are set to protect public health by ensuring good quality water. Private well owners are generally not required to What else should i know about test their drinking water to meet standards,unless the state has water testing? regulations for private well Nesting. However.lending comps- Prior to obtaining a water sample for testing.advise your client nies may use some of these standards for loan approval.Private to confirm that the well has no chlorine in it The well may have well owners and potential buyers can use the public drinking 4 S water standards as guidelines when evaluating the quality of private drinking water. For more information on drinking water Where does your client get quality standards,visit EPA's website: www.epa.gov/sa&water information on the age of the private State drinking water agencies may also set advisory levels for well, the type of well, its depth, and some contaminants,such as sodium,that are either stricter than the federal standards or that are not covered by the federal testing and maintenance records? standards. ° The current homeowner may have testing and maintenance records. and well construction information (also known as a Are there any other parts of the water well log a water well record or a drilling report). Most states system that need to be inspected? require that a registered well driller fele a well log with the state Yes.In addition to a well water test,the mechanical workings of drinking water agency or local town hall.However.depending on the age of the well,this may not have been done. In some the water system should also be inspected.This includes the well cases,your client may be able to contact the individual who pump,pressure tank,water treatment system(should one exist), the condition of the area around the well,and the well's Proxim- constructed the well.If this information is unavailable.then your Central contamination sources.The well itself should be client will have to rely on the information produced by the well h•Y to p° inspector. inspected to ensure tight construction.Also,the well's location should not be subject to flooding.It is important to advise your Determining the well type--whether dug, driven. or drilled— client to rely on qualified professionals to conduct the can often be done by a visual inspection of the well. For more inspection. Qualified home inspectors can inspect the plumbing information on well types, see the University of Rhode Island system.such as general age,appearance and performance of the factsheet DrinkingWaterWells at: piping storage tank and/or other water system appliances like water filters and treatment s.For an in r work viww un•edu/crJwglhaslhtmi/Drenkm8-P system y inspection o on the well,it is recommended to contract with a registered well driller or pump installer. � How does your client determine if the private well will produce enough water What are the costs for inspection? for household needs? The inspection fee for a typical one-family house varies geo- The well log or drilling report may contain the information on graphically,as does the cost of housing.The knowledge gained the well's capacity and yield in gallons per minute.If this infor- from an inspection is well worth the cost. When selecting the mation is not available,you can contact a registered well driller home inspector,the inspector's qualifications,including experi- to conduct a well yield test. This person will have the equip- ence,training,,and professional affiliations,should be an impor- ment and knowledge necessary to conduct the test. tant consideration. Most states have private well construction regulations that require a minimum well depth based on the yield of the well. H; For example,in Rhode island,a well with a yield of one gallon of water per minute is required to have a minimum well depth of ° x 300 feet. A minimum well yield of one gallon per minute amounts . to 1,440 gallons of water per day. By comparison.it is estimated that the average daily water use per person is 75 gallons:for a family of four this amounts to 300 gallons of water per day. v`�"'`.` aha•`� . w3 ' HOUSE ` n FOR However, a well producing less than 5 gallons per minute is still For More Information considered low yielding and may not be able to keep up with too many demands being placed on it at the same time.Water- use chores may need to be spread out over the week to limit U.S_ EPA New England demand. .1 IRM New England Office has a new campaign to get.the word out-to-homeowners aboutthe importance of taking precautions How does my client determine if to protect, maintain. and test their private well.Through a the well is properly located away variety of efforts,the ca;npaign vola reach the general pubrr,the real estate community,schools,local officials,and trade associa from potential contaminant sources? tions rike well drillers. The potential for contaminants entering a well depends upon wwwepa gov/ne/ecafdninicwaber/pr owners.l�trnl its placement and construction.as well as the proximity of the well to potential pollution sources, the condition of the well New'England Region Water-Quality;'Program casing and well cap, and general construction. States have For inforrnatioti and education programs on-private well water minimum setback distances for wells from potential contami- nant sources. Examples include setback distances from septic Pc'POn-ww w.vsawa6enqua!'�tjra.�lneweng�land tanks,leach fields,agricultural operations,and roads.Older wells, consta•ucted prior to the adoption of these setback require- Connecticut ments, may not meet these criteria. States also issue well Connecticut Department of Public Health construction regulations or guidelines that ensure a safe water Connecticues private well water quality regulations are supply.Your client can contact the state drinking water agency contained in Public Health Code Section 0-134101_ for specifics. Encourage your client to find out more about .Wellconstriction regulations are contained in PHC Section private well ownership and use.A guide entitled, Drinking 19-13-1351a-m Private weff regukdons are under the jurisdic- Water from Household Wells is available from the EPA to help tion of-Connecticut's local health departitients.They should be answer questions and provide links to additional information. contacted with any private well questions.Additional informa- The booklet can be viewed at www.epa.gov/safewater/ tion may also be obtained by contacting the Department of pwelisl.htlml or it can be ordered by calling the Safe Drinking Pubfic Health's(DPH) Drinking Water Division PWD)at Water Hotline at:(800) 426-4791. (860)509-7333 or by accessing the DWD's website. ww%vd .ctus/BRS/Water/DVI/D.htm 8 9 R+w./+..r.MtM!.r_•..r..MM.wn..r—...-e.r..... _. •. tet. i. n.n o.•ntP, .._+w.. _ _ _y � ,`._"�?fFiw2 ,r � :. .:. n' t Maine New Hampshire For a list of state certified labs, contact the Drinking Water I The New Hampshire Department of Environmental Services has Program in the Division of Health Engineering; Department of extensive information on its website at:www-desstatenh.us/wseb Human Services (207) 287-1929. For information concerning laboratory testing of water samples, i please call an independent certified laboratory in NH or the state The Environmental Toxicology Program in the Department of laboratory at 603-271-3445. For information concerning water Human Services maintains health based Maximum Exposure ! Guidelines (MEGs) for owners of private wells.The toll free quality,treatment,and questions concerning the public drinking water Program, please call 603-27}-25}3. number is (866) 292-3474. - For information on wells,water quantity,and licensed well The University of Maine Cooperative Extension Water Quality i drillers, please call 603-271-2513. Program has information on private well water protection and 1 For health related information, please call 603-271-4608. testing on their web page. www.umaine-edulwat"ualityl • For water quality gest requirements for new housing,contact Massachusetts your local community's code enforcement program. Local Boards of Health canNations a it { some NH communities have local testing requirements.Contactyour adopt regulations requiring Pim local town hall to learn about any local testing requirements in your. for private drinking water well consavction,testing and abandon- � community mens.Co.i your local Board of Health for more information. t For more information about types of wells, maintaining wells. Rhode island water quality issues and testing well water,visit the UMass Rhode Island Department of Health Extension website. Regulations for private drinking water well testing at time of www umass.edu/n water quarKyrindexJM=I real estate sale and information on testing and state certified laboratories. (401) 222-6867. For InkxTration on state certified laboratories in Massachusetts. www.health.ri.goylenvironment(dwq/privatewe[Lphp see the Drinking Water Program at the Massachusetts ; Department of Environmental Protection website. R1 Department of Environmental Management www•azLte—nuq.dsJdeP/bspdwesifi1es/4atabip.h ndlab To obtain a listing of registered well drillers and pump installers. regulations pertaining to private drinking water well construc- tion and abandonment;call (401)222-4700 or visit the website. w,ww.state.ri.us/dem/programs/benvironlwater/permits/ privwelUindex_ht rn The University of Rhode Island Cooperative Extension Water Quality Program has an extensive private well web page with fact sheets and a program calendar offering private well educa- tion workshops.See www uri.edulcetwq and click on the Rhode Island Home*A*Syst Program link- Vermont inkVermont For technical assistance and other information including health concerns,testing recommendations for private well owners.fact sheets, and diagrams on proper installation of wells, and information about home water treatment,contact the Vermont Department of Health at (802) 863-7220 or (800) 439-8550 (from within Vermont). wwwlwalthyvermonters org/hp/waterqualitylsafewatershtml For more information about laboratory testing services; water testing or to order test kits,contact the Vermont Public Health Laboratory at(802) 863-7335 or,from within Vermont. (800) 660-9997. For information on Vermont Licensed Well Drillers,contact the Vermont Department of Environmental Conservation,Water Supply Division at (802) 241-3400 or (800). 823-6500 (from within Vermont) www.verrnontdrinidngwater.org/welLs.htm Water Systems Council Water Systems Council is a national organization solely focused on individual wells and other well-based water systems not regu- fated under the federal Safe Drinking Water Act.The Council offers educational materials and trainings. t: Wel]care Hotline:(888) 395-1033 �; •_ wwwwatersystemscouncii.org/aboutrndex.cfm American Ground WaterTrustTti This national not-for-profit educational organization focuses on groundwater- resource protection.The Trust conducts training programs and develops educational materials on groundwater resource protection including private drinking water well protection and maintenance. American Ground Water Trust:(603) 228-5444 www-agwtorg or www.privatewelLcom 1) From:North Andover Police Dept. 978 686 1212 06/20/2011 08:42 #078 P.001/001 Northam, Susan From: Allie Hayes[HorseScience@Comcast.Net) Sent: Friday, June 17, 20118:26 PM To: Northam,Susan Subject: Fw:quarantine Forgot to note that I did not get the information until 6-16-11. Was not able to reach Calil's until 6-17-11. Tried to fax the notice I got from the Boxford Animal Hospital, but couldn't get it to go thru to NAPD. -Original Message Flom Alhe Haves <.: To: snortham@napd.us Sent: Friday,June 17,2011 8:21 PM Subject: quarantine /��I; N( Dog "Gomez"owned by Paula Calil, 103 Lancaster Rd., N.Andover(t. 978-975-4248) Bit a dog"Bailey"owned by Lisa Brewin,420 Ipswich Road, Boxford(t.978-352-8976) R-7ry101 Date of bite: June 7,2011 Incident occurred at Best Friends Doggy Day Care in Boxford. Bailey was treated at Boxford Animal Hospital.(T.978-352-8385) Allison Hayes,Animal Inspector Boxford T.978-352-6336 Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:htil)://www.sec.state.ma.us/pre/[)reidx.htm. Please consider the environment before printing this email. 1