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Home My WebLink AboutMiscellaneous - 126 VEST WAY 4/30/2018 (2)> cA ti ro rto b K tt H (D FJ- (D C1 rh A� • • In CD rr •• C (D (n rt BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAM EXAMINATION Permit No#: _ Date Received Date Issued: IMPORTANT: Appli LOCATION must Print �- - all items on this 16'6NO\ F- f PROPERTY OWNER- (25+UUS�Cr hf . Print 100 Year structure yes 0 MAP PARCEL: _ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg 0 Others: 0 Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer Utb(;KIPTION OF WORK TO BE PERFORMED: C©kS6A phi®L pftw e. OWNER: Name: Address: Contractor Name: - Please Type or Print Clearly 2CJ�IN Phone: e hone: Address: Supervisor's Construction License: Exp. Date: Home Improvement: License: Exp.. Date:..__...._ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 P R $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting wp u registered contractors do not have access to the guaranty fund Signature of Agent/Owne Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ElSw"Ming Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT MMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed o Reviewed On Signature_ ks zl- Sianature Reviewed on -1 , 1 S Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes _ no. Located at 124 Main Street Fire Department signature/date ^eNft nn nrAl-rC` x I CErITIFY THAT'THE SEPTIC SYSTEM WAS INSTALLED AS SrhOWNTHIS PLAN IS [10T INTENDED ASA WARRANTY OF THE SYSTEM ALL DIMENSIONS FROM NERD PLAN*91 P �PLAN SHOWING SUBSURFACE ISEWERAGE DISPOSAL SYSTEM AS -BUILT LOCATION LOT 50A VEST WAY OWNER JAYSON REALTY TRUST DATE 6-9-B13 SCALE _1''-40/ F41EPA-RED BY FLYA N SS(-"-- Lp F. -) oo FOX5 9 uj PLAISTOWN.Hc, 665 Commonwealth of Massachusetts City/Town of System Pumping Record At Form 4 PLAY b N14 DEP has provided this form for useby local Boards of Health. Other fo s may be'used, but the information must be substantially the same as that provided here. Befor psirag.tfSis''fori>7, your local Board of Health to determine the form they use. The System Pumpn i fe 3rd 'st "e sutelh itted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of hous. , e Left / Right side of building, Left / Right front of building, Left / Right rear of b� g, Under- Address II i City/Town e state Zip Code 2. System Owner. , mar lk i Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system. ❑ 4. State Zip Code Telephone Number t . Dat 2 1uantity Pumped: Gallons Q Cesspool(s) ;/Septic Tank ❑ Tight Tank ❑ Other (describe): Effluent Tee Filter present? ❑ Yes [ No 5. Condition of System: 6. System Pumped By: If yes, was it cleaned? ❑ Yes ❑ No; Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc - Company 7. Location contents were disposed: t6form4.doc- 06/03 System Pumping Record • Page 1 of 1 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts NU) sw @- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover MA 01845 12/10/2012 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: James Kellett Name of Inspector Kellett Excavatinc Company Name 400 Salem Street Company Address Lynnfield Cityrrown 781-599-7934 Telephone Number B. Certification MA 01940 State Zip Code SI13463 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature 12/10/2012 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover MA 01845 12/10/2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 12/10/2012 State Zip Code Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ ❑ ❑ broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover MA 01845 12/10/2012 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 126 vest way Property Address Paul Connelly Owner Owner's Name nforma equine fo d fotiis r every requireNorth Andover MA 01845 12/10/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® i Area — IWPA) or a mapped Zone II of a public water supply well ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM , • '' 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist MA 01845 12/10/2012 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 126 vest way Yes Property Address No Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code 12/10/2012 Date of Inspection D. System Information Description: 1500 gallon septic tank was installed in 1997. no ponding, no evidence of leakage. exspress importance of annual or bi annual pumping due to amount of scum in tank. Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 272 gpd 9 ( Y 9 (gpd)): Detail: within designed limits Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 12/10/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: pump record gallons pump record maintanence ❑ Yes ® No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , •�'' 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. Citylfown State Zip Code D. System Information (cont.) 12/10/2012 Date of Inspection Approximate age of all components, date installed (if known) and source of information: septic tank 1997 (15 years), leachfield 1983 (29 years) Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 3 feet feet ❑ Yes ® No Distance from private water supply well or suction line: opposite side of house feet Comments (on condition of joints, venting, evidence of leakage, etc.): sch 40 pvc pipe going into tank Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass 1500 aallon 2 feet ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10-6 x 5-8' Sludge depth: 18" ❑ Yes ❑ No t5ins • 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 16" 6" 5" 411 12/10/2012 Date of Inspection How were dimensions determined? measuring rod Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): septic tank in good working order, tank replaced in 1997, inlet / outlet tees in working order, recommended tank to be pumped Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 11/10 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. Cityfrown State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 16" 6" 5" 411 12/10/2012 Date of Inspection How were dimensions determined? measuring rod Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): septic tank in good working order, tank replaced in 1997, inlet / outlet tees in working order, recommended tank to be pumped Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 11/10 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Insp Subsurface Sewage Disposal System For �M , •''y 126 vest way D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.) * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 ection Form m - Not for Voluntary Assessments Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 12/10/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.) * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 wo Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover MA 01845 12/10/2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): dbox just replaced and inspected perfect condition, speed levelers were used for equal disbursement 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.) n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: sas located t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 12/10/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 50'x 25' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) MA 01845 12/10/2012 State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): conditions above sas in qreat shape no ponding no breakout Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) MA 01845 12/10/2012 State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): conditions above sas in qreat shape no ponding no breakout Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 IW Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover MA 01845 12/10/2012 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Site Exam: ® 126 vest way ® Property Address ® Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 12/10/2012 Date of Inspection Estimated depth to high ground water: 5 below exisitng grade feet Please indicate all methods used to determine the high ground water elevation: // U 0 101 0 Obtained from system design plans on record If checked, date of design plan reviewed: 3-1-1983 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: I established high ground water by test pits proformed on 3-1-1983 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code E. Report Completeness Checklist 12/10/2012 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION IFORM PART C ► SYSTEM INFORMATION (continued) s . Vroperty Address: QLCO VQa3t \ N Owner: ,3. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) A,4 -t -3L4 I 3fl `9 `) r v 4DI a 151 1i41 1 4(4 F -� Yl6 i - _ 4c/ 1611% t (r*vissd 04/35/97) giig ! 38 w � + North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 126 Vest Way INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: 104 D LOT: 99 INSPECTIONS TANK INSPECTION: 12/10/12 (D -Box and outlet pipe) DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port I-/ Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ❑ Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: See Picture (D -Box and outlet pipe). Unable to view. Todd Bateson sent in pictures. r a . r t t. „. . a rr;. " � wr is _ • v ^'i r d ^ low v 1 L a x s a. IY F. , i .I •� t � ' � s 4w 401 s ,. Saari � • °�` t �a� a � Rti; �'f+d.i gam. ` ' + x: .. „� " , '1 r+' SG - :° i ;."r •. -,q 1 r� i r � "y... r e , A t mr i OF �i� u • X14 . _ .sa a rr , » ; 'SkI �� '�'.. ice'. � � `, ` "' �'� 4y �•..� �.', F �* r^ � � ."y iLLy It ! +fag ' .: ..' � '� V ' :^ k . " •. �, # ,y F�, ,�., fI+9K u <3 f i � Nb Tr. �r� • �R S�: .A p �F #f 6 x . e Pau AWWWW1 t �m IV, A r a . r t t. „. . a rr;. " � wr is _ • v ^'i r d ^ low v 1 L a x s a. IY F. , i .I •� t � ' � s 4w 401 s ,. Saari � • °�` t �a� a � Rti; �'f+d.i gam. ` ' + x: .. „� " , '1 r+' SG - :° i ;."r •. -,q 1 r� i r � "y... r e , A t mr i OF �i� u • X14 . _ .sa a rr , » ; 'SkI �� '�'.. ice'. � � `, ` "' �'� 4y �•..� �.', F �* r^ � � ."y iLLy It ! +fag ' .: ..' � '� V ' :^ k . " •. �, # ,y F�, ,�., fI+9K u <3 f i � Nb Tr. �r� • �R S�: .A p �F #f 6 x . e •' °� Commonwealth of Massachusetts Map -Block -Lot • 104.D0099 BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair) by Todd Bateson ---------------------------------------------- ---------------------------------------------------------------- -.-- ------------ Installer at No 126 VEST WAY ---------------- ------------------------ .------------------------------------------------------------------ ---- -- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2012-078 Dated December 04 2012 --------------------------------------------------------------- Printed On: Dec -04-2012 BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 104.D0099 BOARD OF HEALTH ------------------- Permit No North Andover -BHP-2012-0784 ------------ ---- ------ FEE $125.00 --------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to (Repair) an Individual Sewage Disposal System. at No --12-6-VE-ST-WAY as shown on the application for Disposal Works Construction Permit No. BHP -2012-078 Dated December 04, 2012 ---------------------- ---------------------------- - -- ---- Issued On: Dec -0 11 4-2012 BOARD OF HEALTH O` MORTM ,� 6 3 + I Fj ♦` , • c9 Town of North Andover HEALTH DEPARTMENT ,sSACHUSE� CHECK #: 1n DATE. -T)!2/ • . u �, WO@a, 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 $ ❑ Other: (Indicate)•' -%5D, OD $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer f Application for Septic Disposal System J tl •,,t° ,�A 3? ' "' .j �' °c TODAY'S DATE =Construction Permit —TOWN OF °ORTH ANDOVER, MA 01845 $ 250.00 -Full Repair & •..... ;,� $125.00 - Component Important: Aonlication is herebv made for a Dermit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your [repair or replace an existing system component -What? / 1 �— �d)C f1- O•- -�/ t cursor - do not use the return key. A. Facility Information / 1 rab Address or Lot #� City/Town � 17A � 4 20 2 2.- *TYPE OF SEPTIC SYSTEM*: ORTH ANDOVER LHEALTH ❑ Pump ravity (choose one) DEPARTMENT ***If pump system, attach copy of electrical permit to application** D<'o-nventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information / Name l c?!l �'esfWAY Address (if different from above) /y, A-4-yVa! t.fZ_ City/Town State 8' Zip Code Coy- o -Telephone TelephoneNumber 3. Installer Information Name Name of Company r r1�f11c , AddressPY4 L 111 ARGILLA ROAD � • ANDOVER, MA 01810 City/Town State Zip Code 9'71 ?/S -d7-03 Telephone Number (Cell Phone # if possible please) 4. UesiQi Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 z /---��_ TODAYS DATE $.250.00 -- Full Repair $125.00.- Component PAGE 2 OF 2 A, FaCMiN.Information continued.... 5. Type - of Building:esidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to. ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andov and not to place the system in operation until a Certificate of Compliance has been lsscj:� Boar Name Date Application proved By: (Board of Health Representative) l Zr— 7__ Name f f' Date r Applicati n Mappr, d. for the following reasons: For Office Use Only: 1 FeeAtwched?: Yes No 2.. ProjectMaaager Obligation Form Attached. Ycs_ No 3.: Pum,�Svstem? Ifso3 Attach copy ofElecbrlcalYeo No 4. Foundation As Built.? (new construction -ronly). Yes No (Same scale as approved plan) a S. F1oorPlans? (hew construction only). Yes_ No ApplTcatiOnorDisppsal Systemonstrciction Permft Page 2 of 2 SEP` IC SYSTEM.�INSTALI EiI'PRGJECT M��►GEMENT OBLIGATIONS for the constLuctioti for.'the septic system .for.the :property at: As the North Andover.lice}nseclinsraller lad V�s� w� . For plans by (Address of septic system) Relative to the.application of a L� �'9N At id dated (in'staller's name) Dated — ji --i'-- With revisiol oaay s aa�e� I understand the following obligations for management of fais project: ,- 1. As the installer, I am .obligated to obtain. all permits and Board of Health approved plans prior to :performing any work on a site: I must have d the permit on site when My work is b'ein_,, done• 2. As the installer,.I mustcall�for any and allinspe��tions: I£homeowner, contractor, .project manager, or any other person not associated with my company schedules -an inspection and the system is not ready, then item three- shall.bei applicable. As .thy installer, I aW.xequired to. have .the necessary work'cQmpleted prior to the .applicable inspections as indicated below: titrdeistand that re iiestin.�; $Int spe on without comtiletion of the items in. accordance with Title 5 and the Boafd of pTeaitli Re�2lilaiions relay resultin a $50 OO fine beuie.levted aQalnst:me..and or a...�o'tfonibf.B.ed �-Generally, this'is the.4st: 1' lns e.. A unless. there is a "retainingwall, athich show' d bd done< t 'Tlie uistalf must rpgpest the *spect orl but does not have to be present. b. Final Con d on.InsPeetioti — Erig necxIftust first:do their ii�sj ection for elevations;'ti'es, etc. As-l�iiilti of verbal OK (or e-mail'to: heal_ townofriorthandover.com) from the engineer must be subniitted to ..the.Bo'ard-of.Health, aftez.which: nstaller.calls 'for.an inspection tune. Installer must be present for this.inspection, With -a pump system, all electrical work.xnust be ready and able to cause;pump.t6-vt ork an4!alarm.16 function. . c. findfGtade — Ihstaller must request inspection tvhen'4'grading is complete.. Installer does not have to be •on-site. ' As •the installer,' I unciersfand that only I My perform the vork (other than rimpk excavation) and I Anirequired to coffipleze the installation of the system identified in xlie attached application for. installation: :I farther . 5.. As the.instiller,�I uisderstani d G. during the.perf&niance of the following construction. steps:.. a: Determinatioti that -the proper efevadon of the eirrear2tion has been reached b. ins peetion ofthe`sand and stone to be used. c. ' Final inspection by Boar4 of staffor consultant. d. Installation..oftanlc, D Box pipes, stone, vent, pump chamber, retairrg walland other components. Undersigned Licensed Septic.Installez: (rodo Late) 6 321 �r•`Y cp • Town of North Andover HEALTH DEPARTMENT ,SSwCHU CHECK #: �� DATE: LOCATION: H/O NAME: CONTRACT( Type of Permit or License: (Check box) 0 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 Inspecto Q)-t Q $� bi n-tf �m ,i Title 5 Report ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. -� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover City/Town MA 01845 11/29/2012 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: James Kellett Name of Inspector Kellett Excavatinc Company Name 400 Salem Street Company Address Lynnfield City/Town 781-599-7934 MA State S113463 Telephone Number License Number B. Certification it %6. oY Ya li V ll:�;m k.I DEC 0 4 2012 TOWN OF NORTH ANDOVER HEAL3 h DEPAR i NiC 1 01940 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature 11-28-2012 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 owl Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 11/29/2012 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 11/29/2012 State Zip Code Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ® broken pipe(s) are replaced ❑ obstruction is removed ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): outlet pipe from septic tank to dbox is either broken or just has to much pitch so that the tee in tank is touching top of tank. also dbox is really corroded and needs replacement. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 11/29/2012 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/ day flow t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner Owner's Name quire tifo isr every reequired foNorth Andover MA 01845 11/29/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well i ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 ,t Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C. Checklist 11/29/2012 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 126 vest way ® ❑ Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code C. Checklist 11/29/2012 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): A A Number of bedrooms (actual): A A A DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ay'' 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 11/29/2012 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 gallon septic tank was installed in 1997. no ponding, no evidence of leakage. exspress importance of annual or bi annual pumping due to large amount of scum in tank. Number of current residents: Does residence have a garbage grinder? 1) ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d unavailable 9 ( Y 9 (gP ))� Detail: due to time urgency of report was not able to get water readings *last title v report they came up with 440 gallons per day.* Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 , Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM a °y 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: pump record gallons pump record maintanence current Date Type of System: ® Septic tank, distribution box, soil absorption system 11/29/2012 Date of Inspection ❑ Yes ® No ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 126 vest way GSM SyO� Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code D. System Information (cont.) 11/29/2012 Date of Inspection Approximate age of all components, date installed (if known) and source of information: septic tank 1997 (15 years), leachfield 1983 (29 years) Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 3 feet feet Distance from private water supply well or suction line: opposite side of house feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1500 gallon 2 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10-6 x 5-8' Sludge depth: 18" t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 11/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 16" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 4" How were dimensions determined? measuring rod Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): heavy scum and sludge due to lack of pumping. outlet tee needs repair Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 11/10 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 11/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 11/29/2012 Date of Inspection Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): dbox corroded needs replacing 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.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: sas located t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Insp Subsurface Sewage Disposal System Fo 126 vest way D. System Information (cont.) Type: ection Form leaching pits rm - Not for Voluntary Assessments ❑ leaching chambers number: ❑ leaching galleries Property Address ❑ leaching trenches number, length: Paul Connelly leaching fields number, dimensions: Owner Owner's Name number: ❑ information is required for every North Andover MA 01845 11/29/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 50'x 25' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 as Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 vest way Property Address Paul Connelly Owner's Name North Andover MA 01845 11/29/2012 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): conditions above sas in great shape no ponding no breakout Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11/29/2012 Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code 11/29/2012 Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Site Exam: 126 vest way Check Slope Property Address Surface water Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11/29/2012 Date of Inspection 5 below exisitng grade feet Please indicate all methods used to determine the high ground water elevation: // ❑■ ❑■ ❑■ ■❑ Obtained from system design plans on record If In kddt f iI d' 3-1-1983 c ec e, a e o U0 U" p an revlewe . Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: I established high ground water by test pits proformed on 3-1-1983 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts a - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 126 vest way Property Address Paul Connelly Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 11/29/2012 Date of Inspection ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: QG V ea;k Wa.,Qo `� Owner: Date of Inspection: Chs► .. 10�-��rq�1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) i I A -40A 34 a = 3ci q 11 Q.09W y ff 44�If _ t6 r� 1 It 6 1 It t V4CUSQ. S3 -j- w4er (sovised 04/111/97) l', grlge 9 (at= ui It Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P 126 vest way_ _ Property Address Paul Connelly Owner owner's Name v information is required for every North Andover MA 01845 11129/2012 _. _. _ _ _ page. CityrTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out forms A. General information on the computer, use only the tab 1. Inspector: key to move your cursor - do not James Kellett_ use the return key. Name of Inspector Kellett Excavating — _ __. Company Name 400 Salem Street Company Address Lynnfield MA 01940 Cityrrown State Zip Code 781-599-7934 S113463 Telephone Number license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the t cal Approving Authority - _ _ . .. ............ ----- -- . -/4A11-28-2012 1 ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11110 Title 5 Offioal Inspection Form Subsurface Sewage Disposal System • Page 1 of 17 Board of Health ,H4MAk�!AhdoverjXass APPROPED DATE -7 Provided: SUBMRFACE DISPOSAL DESIGN CHECK LIST LOT � `s DISAPPROVED DATEj ed -7 Reasons: � -� V 72!-7— P17-5 IV&7- „c/ Title V FAIL _ Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served -area, dimensions lot #,abutters 4 b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area e) location and dimensions of system -including reserve area _ f) existing and proposed contours g) location any vet areas within 100' of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of seiage disposal 11 system or disclaimer -Planning Board files (j) knom sources of water supply within 2001 of sewage disposal e system or disclaimer, �•� k) location of ant proposed well to serve lot -1001 from leaching facilit,�, ) location of water lines on property -101 from leaching facility M ) location of benchmark driveways gage disposals 7 no PVC to be used in construction JJ (q) profile of system -elevations of basement, pl4j pi e, septic tank, distribution box inlets and outlets, distribution field piping and 0tker elevations maxi=m ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other __--i professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capac t es -150% of flow, water table, tees, depth of tees, access, pumping cleanout c) 101 from cellar vml.l or inground swimming pool i (d) 251 from subsurface drains Reg 10.2 Distribution Boxes slope greater 0.08 Reg 10.4 b) sump Subsurface Design Check List Pae 2 FAIL I Og Reg 11.2 11.4 11.10 11.11 Reg 15.1 15.4 15.8 3.7 Reg 14.1 14.3 14.4 14.6 14.7. 14.10 Reg 9.1 9.6 Leaching Pits Leaching pits are preferred where the installation is possible a) calculations of 1 -.'h4-ng area-adnimum 500 sq ft b) spacing c) surface a 2% al e) k'x2plash pad d) coveZd�sin f) tee ow g) no pipe from d -box to pipe Leaching Fields a) no greater than 20 minutes/inch b) area -minimum 900 aq ft c) construction of field ) surface drainage 2 % e) 201 from cellar wall or inground swimming pool Leaching Trenches� a) calculations of leaching area -min 500 aq ft b) spacing -4 PeMm 6 ft with reserve between c) di.mensi d) cons ction le) s e f} farce 2% Dounhil.l Slope s ope y x to be shorn) b) y/x X 150 - (to be shown) PW s ) approval stand-by power / J V �a) 4/ba) { • ra of Ht- _,'_th SUBSURFACE DISPOSAL DFMMI CHBOK LIST APPROVED ` DATS� DISAPPROVED Provided: Reasons: 117 pr f:N DAT$______ LOT f150 Jc sT Title V Reg 2.5 Reg 6 FAIL CK The submitted plan must x as a a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area e) location and dimensions of systems -including reserve area f) existing and proposed contours g) location any Wet areas within 100' of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files (j) known sources of water supply within 2001 of sewage disposal d system or disclaimer ( location of aril proposed well to serve lot -1001 from leaching facilit location of waster lines on property -10' from leaching facility ) location of benchmark driveways garbage disposals no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations maximum ground water elevation in area sewage disposal system S) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such. plans Septic Tanks a) capacities -150% of flow, pater table, tees, depth of tees, access, pumping b) cleanout 10t from cellar wall or inground swimring pool (d) 251 from subsurface drains ., / Reg 10.2 Distribution Boxes .- t (a) slope greater than 0.08 Reg 10.4 b) SUMP I rAn I M Leaching Fits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-ndniaum 500 eq ft 3.1.4 b) spacing 11.10 c) surface drainage 2% 11.11 d) cover material e) 2'x2Ix4O,. splash pad f) tee at.falbox g) no triads in pipe from d -box to pipe Leaching Fields Reg 15.1 AQ no greater than 20 minutes/inch area -minimum 900 aq ft 15.4 construction of field 15.8 surface drainage 2 % 3.7 e) 20' from cellar Wall or inground awimming pool Leachin gtmches Reg 14.1 U.3 14.4 14.6 14.7 14-10 Reg 9.1 9.6 a)—calculations of leaching area -min 500 eq ft b) spacing -4 ft An 6 ft with reserve between c) dimensions d) construction e) stone f) surface drainage 2% Dowahi.11 Slope a) slope —77x to be shoun) b) y/x X 150 = (to be shown) Eums a) approval stand-by power _(b) TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: Y'l3 -61 TEM OWNER & ADD ov,vt-e 11 SYSTEM LOCATION (example: left front of house) SAC 6V 6ps-p'- DATE OF PUMPING: "C "8 ( QUANTITY PUMPED t-5"'0'— GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE YEMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: 6 • ,—/ - 5—, F �S. , ELEV BEh:CHtJARK 0 TOP FND- ISO -70 INV. HOUSE 148Z1 SJINLET O_ i 14U4 D -BOX INLET n D -BOX OUTLET 142023 N N OX 30 oU'1 � , O Z V LOT 50A 3,05 of ti 071)O O �tt DES-CRIPTION ELEV BEh:CHtJARK 13 59 TOP FND- ISO -70 INV. HOUSE 148Z1 SJINLET 143.09 S.T. NUTLET 14U4 D -BOX INLET 142,71 D -BOX OUTLET 142023 END OF FIELD 142oU6 { t i CERTIFY THATTHE SEPTIC SYSTEM WAS INSTALLED AS Si ;OWN -THIS PLAN IS HOT INTENDED AS A WARRANTY OF THE SYSTEM. ALL DIMENSIONS FROM NERD PLAN*91 I: PLAN SHOWING SUBSURFACE SEWERAGE DISPOSALSYSTF-M - AS -BUILT LOCATION LOT 50A VEST WAY OWNER JAYSON REALTY TRUST DATE 6-9-613' SCALE I�'=40' PREPA-RED BY I FLYAll"A'), Asso P ao /90X.`:_6' 9 pl_,41S-FOWNH0 a��5 -Toe cd WdTZ:ZO L66T 9F3 ""ON : 'ON 3NOHcl *ON I BDI()83S 83fi3s s,J,onos : w08j 4:4 cd WdTZ:ZO L66T 9F3 ""ON : 'ON 3NOHcl *ON I BDI()83S 83fi3s s,J,onos : w08j Town of North Andover, Massachusetts BOARD OF HEALTH Nov. 6 CERTIFICATE OF COMPLIANCE Form No. 4 19 97 This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (X ) John Soucy Septic Tank Only byINSTALLER at .L Vest Way SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. N.1 A" dated 19 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. -� BOARD OF HEALTH