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Home My WebLink AboutMiscellaneous - 131 PHEASANT BROOK ROAD 4/30/2018 (2) r -- 131 PHEASANT BROOK ROADbk Road � 210/106.6-0226-0000.0 ,l I nl''"-ZT .;t ' ,..< ,+'� i�� 1 ^P14��i t^Y',"�% . 1 I •`1 .� �'}��jt„'�"yy�tr” !7 t- a a f, r r } li kt ilk r`r ✓.; k ;� ►.1 r 1tF� . . MAR # ,, ' �,? ' LOT �+ r PARCEL # STREET CON.STRU.CTIQN_AP _OVA. HAS PLAN REVIEW FEE .DEEN PAID? YES NO PLAN APPROVAL: DATE APP. BY DESIGNER: orf 7�/`' PLAN DENTE. CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT WELL TESTS: CHEMICAL DALE APPROVED.-.-___-.-.__- BACTERIA I DAIE f1PPRUVEU BACTERIA II DATE APPROVED _ COMMENTS:. FORM U APPROVAL: APPROVAL. TO ISSUE NU DATE ISSUED-<5/6 /6--By CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL "- NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES" NO OTHER YES NU ANY VARIANCE NEEDED YES FINAL BOARD OF HEALTH APPROVAL: DATE:� i� Y�_ ....BY : _. 5EPTG�SY�t "1_�NSI81. TQ�I Lr' c YES NO x~ INSTALLER LICENSED? j- L x' IS THE INSTA t ' ;t < NEW REPAIR— TYPE. OFIyCONSTRUCTION: NO .NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO 14 1_.�.,' COND IT I ONS OF:.APPROVAL . �� , • s (FROM FORM U) NO ISSUANCE OF DWC PERMIT "�'� * •, y /INSTALLER. ZiE/d(I1S DWC PERMIT N0. -BEGIN INSPECTION . • i EXCAVATION •INSPECTION: NEEDED: PASSED _• �:__ - �. - CONSTRUCTION INSPECTION: ;; • NEEDEDi } .t ..• AS BUILT PLAN SATISFACTORY: ES: Y APPROVAL. TO BACKFILL: DATE: ! BY " FINRL•GRADING APPROVAL: DATE �. ' FINAL CBY ONSTRUCTION APPROVAL: DATE: l/ r J 4 RECEIVED OC/. ANDOVER 1O��1 TOWN OF HEALT UA ,:� 9e JYBT-B1,•t PIJMPINu RPC�OkI... �Y51'2M OwNQRt ADpi5s —__�_�_- .__._ S YS TE 6&Z L �,.�_. ..... ... ...QOANT1TY Pl! MPEG f` t�IPOO L; N ruKb G,w sr✓Rvlc . x�v'rIN� L) ► GOOD CONO ' �'v►.:. r , �AYY 01�3 g RG�T� ��'Yl.BS !N PLAI., PLOOD�D SOL CD CA IVB YO YUR _..o me R EXPLAIN �'uMMaNTs. vN I fr1Y I'� rX.�N�l�x1�u r� i � _ t4O R-own Tpy ® _ \- - ®ver _ 3. M INTO. � _ gas Aj dower, Mass., 9' 1978 o . 01 . COCH CHEWICK i� `, '9 T P � OAA S DE ` BOARD OF HEALTH Food/Kitchen P F. M IT T Septic System THIS CERTIFIES THAT.............. �..� / ��/� , . BUILDING INSPECTOR ......................... ... . �........................... a IN Foundation has permission to erect...........�.......................... buildin s on ...... .../®� .. ' � ...r.. .AV.... Rough �J�y ��a-)/CISH uv�A r,CI''kS K M v N /� �..t !eJV.0�. • Chimney `� c3°I X19 to be occupied as............�.......... . ...................... ....................... .......... ................................... v provided,that the person accepting is permit shall in every res ect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPEC Oglk, VIOLATION of the Zoning or Building Regulations Voids this Permit. C PERMIT EXPIRES IN 6 MON Final/ 170 PERMIT ELECTRICAL SP CTO UNLESS CONSTRUCTI� S e Rough BUILDING INSPECTOR.............. D'otvA .... ..................... ......................... Se Final Occupancy Permit Required to Occupy Building GAS INSPECT,-IR Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. . Burner Street No. Smoke Det. L 01 JUPd 1999 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System(� ) constructed; ( )repaired; by ko �4j :¢) 'i,s located at / S/ P&A6j 1+ ,R,r eco K )ed. rtsf JrV e,.r was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# dated 1111411 with an approved design flow of ` gallons per day. The materials used vere in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: V%/ 3/98 Inspector Final inspection date: . 11h(P/58 Inspector Installer: 7 4 2 — Lic. #: Date: 10-- 9 Design Engineer: _ n.�, `Y�'1c9i,,;,, Date: C/►099 M. Town of North Andover, Massachusetts Form No.3 • f"00 Tot BOARD OF HEALTH d (� Q O� .•o,•• 1 p / O } l9 • �'�•:,.e.%w`e� DISPOSAL WORKS CONSTRUCTION PERMIT • '�as,K�s� ApplicantNAM " EADDRESS TELEPHONE Site Location LAT �V-•tJ`C ,g�.�i ,��_,�1'. ,,�, Permission is hereby granted to Construct j)() or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. %�; CHAIRMAN,BOARD OF HEALTH ' � N Fee D.W.C. NO. /o5z- APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: /L,f LICENSED INSTALLER: f k SIGNATURE:-G�� LO �f' .�„ � TELEPHONE# J Z l 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 Floor Plans? Yes No Approval Date: 1�/�Q19 r TOWN OF NORTH ANDOVER BOARD OF HEALTH \ CERTIFICATE OF COMPLIANCE \ DATE OF COMPLIANCE: 06/11/99 This is to certify that the individual subsurface disposal system constructed (X ) or repaired ( ) by Robert Innis at (Lot 8 Evergreen Estates) 131 Pheasant Brook Road has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 816 dated 04/15/96. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector 3 _ _ .`ate _ `� r� i 1� . .. !" y �. "�.. 4 I i� I, �i, � j � _ _ - _ uL.� C y � . a, t �� + t � J 1 f tf �. � ' f'" s _ �� ` � _� � i 1 r �. tt � a>' �1 I'� r .��,3. 'P, _ dd � o"Y ., � h �,. �s � ._ _ __ _ L�`, _ � _ -_---_ � -�_ - __ �___ Tom"""- .. _ I '--. �-_� � I.. (..s./4-71 J AS-BUILT CHECKLIST i LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER r LOT LINES & LOCATION OF DWELLINGS LOCATION & DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA V LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D-BOX STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW b FINAL CONTOURS i • • LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN _—_ - a � _ .-..:A.. ' �` ''� y. ,� i II C'1��.-� ��- I ', ,. FORM U - LOT RELEASE 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION****�`** �" ***** APPLICANT �JQI C ( t I PHONE 4)014 LOCATION: Assessor's Map Number 00 6 PARCEL SUBDIVISION � e� '�STT� S LOT (S) L STREET � i�Se'" 1 DI`0(_ ST. NUMBER OFFICIAL USE ONLY******************* RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED 19 8 i DATE REJECTED COMMENTS PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE r SEPTIC PLAN SUBMITTALS LOCATION: tom" lU� �� eSTT—t- S NEW PLANS: YES $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: I g DESIGN ENGINEER: CN2IS-p&v"k- / �� I When the submission is all in place, route to the Health Secretary 1A car s - { 0-(AAE if - Town of North Andover, Massachusetts Form No. 1 NORTH ��••'. BOARD OF HEALTH o�tt QED bq,•r� / � .J o� 19 0 w A 4E �: } pq .�"t '` APPLICATION FOR SITE TESTING/INSPECTION ol, 9SSACHUS�� I Applicant— NAME J ADDRESS TELEPHONE Site Location /t'.W_-A �-, � v� S 7k Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time N CHAIRMAN,BOARD OF HEALTH ` Fee /52) Test No. f S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 AORTH q BOARD OF HEALTH0 19 � Q SLED ib O APPLICATION FOR SITE TESTING/INSPECTION 7q A�AATEo APp�(5 SSACHUSE Applicant NAME ADDRESS TELEPHONE Site Location Engineer �'�/t•t �, t ^�`-�,-E NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee �� . Test No. 7C S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. i SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan L REVISED PLANS: YES $25.00/Plan V/ p� s C�—�`� D DATE- DESIGN ENGINEER: When the submission is all in place, route to the Health Secretary i FORM U - LOT RELEASE 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 or requirements. *************APPLICANT FILLS OUT THIS SECTION****—*****—***"'***"* APPLICANT "!e7g!C ) PHONE �� -1-;-5- UU1)C) U/� LOCATION: Assessor's Map Number �(0 6 PARCEL SUBDIVISION � e�� '�ST�rT� S LOT (S) STREET � iPrSe'" yl�^+�� ST. NUMBER ****************************OFFICIAL USE ONLY******************* RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMIPOSTRATOR DATE APPROVED DATE REJECTED COMMENTS i TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED /�3 9 8 DATE REJECTED COMMENTS 'PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE The gbottom of bed; ( ) septic system located at 4D7— f f �/�S�JiVTU�'O��C, has been inspected and approved on V /D /�/ by Board of Health personnel, and the Health.Department has no objection to a construction permit being issued for this lot. Inspector Date September 3, 1997 Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 RE: Evergreen Estates subdivision Dear Phil: l This letter is to inform you that the proposed septic plan for Lot 8 Pheasant Brook Road has been approved. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator cc: Wm. Scott, Dir. CD&S DECM File J PLAN REVIEW CHECKLIST ADDRESS ENGINEER GENERAL 3 COPIES 1/ STAMP V LOCUS NORTH ARROW SCALE N CONTOURS (/ PROFILE CL,--' SECTION BENCHMARK SOIL & Pcv�Sf PERCS �S/ ELEVATIONS WETS.. DISCLAIMER' WELLS & WETS `�� WATERSHED?A DRIVEWAY ,/ (Elev) WATER LINE 1,,X FDN DRAIN 2/ SCH40 TESTS CURRENT? t/ SOIL EVAL SEPTIC TANK MIN 150OG L,1/ . 17 INVERT DROP GARB. GRINDER A/0 (+200% EDF) 25 ' TO CELLAR YL MANHOLE ELEV GW # COMPS. Z_ D-BOX 4. SIZE # LINEST 2 ' LEVEL STATEMENT- INLET f��'�� - OUTLET 211 OR . 17 FT) TEE REQ'D?4/6 LEACHING MIN 660 GPD? / RESERVE AREA &,---"4 ' FROM PRIMARY?,�"Z 2% SLOPE 100 ' TO WETLANDS 100 ' TO WELLSi,-' 4! TO S .H.GW (5 ' >2M/IN) 35 ' TO FND. & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY ? MIN 12" COVERy� FILL? x (25 ' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) 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 0 1995 by S.L. Starr i i i CHRISTIANSEN & SERG1, INC. Prvfessional-Enginsers & Land Surveyors MEMO 160 Summer.Street Haverhill, MA 01830 (508) 373-0310 FAX (508) 372-3960 TO: DATE SUBJECTOV � i1�4✓��r/� e�it 219g� � . a NG 1 4 SIGNED, ❑Please reply ❑ Nora*necessary ,PITS MIN 660 LEACHING MIN 1 (131x16 ' ) 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 D 900 ft2 BED �� T1211 `4 BELOW BOTTOM 0`F FIELD PIPE ENDS JOINED? L---' 4" PEA STONDIST LINE SLOPE .005? >3 'COVER-VENT �.-� SCH COVER �--- RATE LDG X 660 X TOTAL IW7446 G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1 ' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH Copyright m 1995 by S.L.Starr D � �� G Town of North Andover OF HORTIy OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES p 146 Main Street • Z i North Andover,Massachusetts 01845 o-• `y,(5 SSgCHUs�� March 27, 1996 Christiansen& Sergi 130 Summer Street Haverhill, MA 01830 Re: Lot #8 Pheasant Street Dear Phil: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. No perc tests in system area. 2. Gas baffle required on outlet tee of tank. 3. Leach area not 10 feet from slab. 4. Leaching area less than 100 feet from wetlands. 5. No benchmark on plan. 6. No site evaluation/soil log sheets. 7. Please state slope of distribution lines. 8. Design of field does not allow for equal distribution/loading throughout field. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, 1 1�2 Sandra Starr, R.S., Health Administrator cc: Bob Messina BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 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 l/ Qk � c Lot(s) Street 3IC St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: C . Date Approved "Conservation rva tion, Administrator Date Rejected I �I. Comments Date Approved Town Planner Date Rejected Comments ih Food Date Approved - Ins ec Hea for t p 1 h Date Rejected PP Date Approved Ii Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections driveway permit Fire Department Received by Building Inspector Date ry CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 April 3 , 1996 Ms . Sandra Starr Tp ,NF rirt� North Andover Board of Health s�A 0��DOVER/ 146 Main Street ,� No. Andover, MA 01845 APR - 5 RE : Lot 8, Evergreen Estates - Dear Sandy: CL 1' In response to your letter of March 27, 1996, I offer the following information. 1 . The perc test location have been added 2 . Gas baffles added. 3 . Leach ares is 10 feet from slab, label of distance added. 4 . The leach area is 100 feet from the wetlands . See 100 ' buffer offset line on the plan. 5 . A bench mark has been added. 6 . Soil logs are attached. (Similar to your suggestion of Steve signing the plan. ) 7 . Slope of distribution lines have been added. 8 . I used a 12 outlet, D-box. 5 pipes go to the largest part of the filed - 42% 4 pipes go to the middle section of the field - 33% 3 pipes to the smaller section of the field - 25% The five pipes discharge into an area of 492 square feet which is 41% of the leach area. The four pipes discharge to an area of 396 square feet which is 33% of the field. The three pipes discharge into an area of 312 square feet, which is 26% of the required area. Starr/4/3/96 page 2 The 1% difference is well within the accuracy of the design. This design allows equal distribution of effluent in the field. Very tro hi C I i n "'ORAL PGC;lc i I I i w FORMM 11 - SOIL .EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Determination for Seasonal High Water Table Method Used: see ��`'� �sf ✓'�� lo�� ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side of observation hole .................. inches ❑ Depth to soil mottles inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ................... Index well level ................... Adjustment factor ................... Adjusted ground water level ........................................................ 3 F 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? If not, what is the depth of naturally occurring pervious material? I Certification I certify that on (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature r Date k 9 DEP APPROVED FORM-12/07/95 -------------- TEST PIT 8-1 DATE: 4/6/95 0 DLSCWPTION RF CE t30,8 A. FTNE SANDY LOW RNE SUM LOW C: 3.813/3 COMM SANDY LOAM FRIABLE t t8 LS.H W.T. O 33': MOTTUNO tt3. lb SEEPAGE 0 A8" TEST PIT 8-2 DATE: 4/6/95 la Ci DOMPTfOwf 1 m5d a A. SANDY LOAM GRAVELLY SANDY Umm RBABBF - UASOYE FRIMtIL33 O 3f.- NOTTUNG NANOANW STAINS O B4'iiQ33 O 86' TEST PIT 9-1 DATE: 4/6/95 DESC MPTbN SMCE- tom, A: FINE SANDY LOAM M RNE SANDY WO t t. 38 5YS/4 NA LLY SANDY LOAM MASSIVE FRUBLE - AAWW FM 119AW E.S.N.W.T. O .W: NOTTUNO TEST PIT 9-2 DATE: 4/6/95 5 € DESCIWPTM 121.00 DfA-, CE 190.5 SANDY LOAN BVh FOE SANDY LOAM 4 OAA LLY SANDY LOAN FINABLE - MASSIVE FIRM 11& T. O IW.- NOTIUNOO 112. tG4 i DATE A Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER ` SUBSURFACE DISPOSAL DESIGN REVIEW FEEPERMIT # DATE RECEIVED APPLICANT ESS//1//9- ASSESSOR'S MAP ADDRESS PARCEL # LOT ## I STREET —///��61)tQT --5.acc ENGINEERG.A1;e1ST/ x),5 ADDRESS PLAN DATE //1� /� REVISION DATE CONDITIONS OF APPROVAL: APPROVED c� / DISAPPROVED X T6-57-5 /A,) 5 Y 5 O k) 007-66-7 T, T/9/U)r- A)O �3 i1/G�v/►�/a/2� OBJ �� 7 /Up .5/7 g7 E►lA.c-U/3 7 OA-)l 5 0 LOG 5/4,G-`QTS. -PG�/95 C L-57297� �Go�� D� -Jl /ST.e/AUT/l>.C� /ifJEs AJOT /9666) ✓-.. .✓mil // ,� Notice to APYL1GAXC/T V CLERK and Certification of A .on of rlanrung Board on Definitive Subdivi bion Plan entitled: -------------- Evergreen Estates BY: Christiansen & Sergi dated 19 94 The North Andover Planning Board has voted to APPROVE said plan, subject to the following conditions: 1. That the record owners of the subject land forthwith execute and record a "covenant running with the land", or otherwise provide security for the con— struction of ways and the installation of municipal services within said sub— division, all as provided by G.L. c. 41, S. 81—U. 2. That all such construction and installations shall in all respects conform to the governing rules and regulations of this Board. 3. That, as required by the North Andover Board of Health in its report to this Board, no building or other structure shall be built or placed upon Lots No. as shown on said Plan without the prior consent of said Board of Health. k. 'Other -conditions: -z ;o See attached o 7Z C:" "77 f o' -•7,. � c c.� Lr In the event that no appeal shall have been taken from said approval within twenty days from this date, the North Andover Planning Board will forthwith thereafter endorse its formal approval upon said plan. The North Andover 'Planning Board has DISAPPROVED said plan, for the following reasons: NORTH ANDOVER PLANNING BOARD Date: August 15, 1995By: 4 JosepiL G. Mahoney, Chairman FORM C APPLICATION FOR APPROVAL OF DEFIMTIVE K Lay C E i•i'•.A 3::.:'`H 0 W CL.E.Rt NORTH 000YER January 17l9 95 To the Planning Board of the Town of North Andover: The undersigned, being the applicant as defined under Chapter 41, Section 81—L, for approval of a proposed subdivision shown on a plan entitled Definitive Subdivision Plan "Evergreen Estates" located in Norrh Andover by Christiansen & Sergi , Inc . dated December 28 . 1994 being land bounded as follows:Northerly bt Com of MA , land of Steer and Fried ; easterly by land of Fried , Deadder , Rough , Green , Galeassi , Yourre , Mateja , Farr and Com of MA; westerly by Com of MA.. hereby submits said plan as a DEFINITIVE plan in accordance with the Rules and Regulations of the North Andover Planning Board and makes application to -the Board for approval of said plan. 1087 314 Title Reference: North Essex Deeds, Book 2901 , Page 13 ; or Certificate of Title No. , Registration Book , page ; or Other: Said plan has( has not( ) evolved from a preliminary plan submitted to the Board of A u d 24 19 94 and approved (with modifications) ( ) disapproved (X) on O c t 4 r 1994 The undersigned hereby applies for the approval of said DEFINITIVE plan by the'Board, and in furtherance thereof hereby agrees to abide by the Board's Rules and Regulations. The undersigned hereby further covenants and agrees With the Town of North Andover, upon approval of said DEFINITIVE plan by the Board: 1. To install utilities in accordance kith the rules and regulations of the Planning Board, the Public Works Department, the Highway Surveyor, the Board of Health, and all general as well as zoning by—lags of said Town, as are applicable to the installation of utilities within the limits of ways and streets; 2. To complete and construct the streets or ways and other improvements shown thereon in accordance -with Sections Iv and V of the Rules and Regulations of the Planning Board and the approved DEFINITIVE plan, profiles and cross sections of .the same. Said plan, profiles, cross sections and construction specifications are specifically, by .-reference, incorporated herein and made a part of this application. This application and the covenants and agree— ments herein shall be binding upon all heirs, executors, administrators, successors, grantees of the whole or part of said land, and assigns of the undersigned; and 3. To complete the aforesaid installations and construction within two (2) years from the date hereof. . Received by Town Clerk: ��- Signature of Applicant Date: Messina Development Corp . , 805 Winter St . Time: North—Andover , MA 01845 Signature: Address y a. A complete set of signed plans, a, copy of the Planning Cr Board decision, and a copy of the Conservation Commission ,_ Order of Condition must be on. file at the Division of Public Warks prior to issuance of permits for connections to utilities. The subdivision construction and installation shall in all respects conform to the rules and regulations and specifications of the Division of Public Works. b. All site erosion control measures required to protect off site properties from the effects of work on the lot proposed to be released must be in place. The Town Planning Staff shall determine whether the applicant has satisf ied the requirements of this provision prior , to each lot release and shall report to the Planning Board prior to a vote to release said lot. C. The applicant must submit a lot release FORM J to the ISI Planning Board for signature. d. A Performance Security (Roadway Bond) in an amount to be determined by the Planning Board, upon the recommendation of the Department of Public Works, shall be posted to ensure completion of the work in accordance with the Plans approved as part of this conditional approval. The bond must be in the form of a check made out to the Town _ of North Andover. This check will then be placed in an interest bearing escrow account held by the Town. Items covered!by the Bond may include, but shall not be limited to: j i. asbuiit drawings ii. sewers and utilities j iii. roadway construction and maintenance iv. lot and site erosion control V. site screening and street. trees vi. drainage facilities vii. site restoration viii. final site cleanup e. Three (3) complete copies of the endorsed and recorded plans and two (2) certified copies of the recorded approval, Covenant (FORM I) , Right of Way subdivision , s PP easements, and FORM M must be submitted to the Town Planner as proof of filing. 4 . Prior to a FORM U verification for an individual lot, the following information is required by the Planning Department: a. All lots must be approved by the Board of Health. The Board of Health has determined that Lots 6, 9, 12 , 13 , and 21 cannot be used for building sites without injury 4 to the public health without further testing. No building or structure shall be placed upon these lots without -consent by the Board of Health. b. Due to' the large amount of rock on the site which may interfere with the amount of parent material available for leaching, the Board of Health will require that the leaching area for each lot be completely excavated to insure that there is the requisite four feet of parent material present throughout the entire location proposed for the leaching area. C. The applicant must submit to the Town Planner proof that the FORM J referred to in Condition 3 (c) above, was filed with the Registry of Deeds office. d. A plot plan ,for the lot in question must be submitted, which includes all of the following: i. location of the structure, ii. location of the driveways, location of the septic systems if applicable, iv. location of all water and sewer lines, V. location of wetlands and any site improvements required under a NACC order of condition, vi. any grading called for on the lot, vii. all required zoning setbacks, viii. location of any drainage, utility and other easements. e. All appropriate erosion control measures for the lot shall be in place. Final determination of appropriate measures shall be made by the Planning Board or Staff. f. All catch basins shall be protected and maintained with hay bales to prevent siltation into the drain lines during construction. g. The lot in question shall be staked in the field. The location of any major departures from the plan must be shown. The Town Planner shall verify this information. h. Lot numbers, visible from the roadways must be posted on all lots. 5 . Prior to a Certificate of Occupancy being requested for an individual lot, the following shall be required: a. A stop sign must be placed at end of Pheasant Brook Road where it intersects with Salem Street. b. 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Applirtt#iott for Iliq1twal Maim (Nimitrar#iott j1pruti# Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: !�1....C—1. 7? ................................ ... ...................... Location-Address • - or Lot No. �� 5 r"�✓A. 17� P!t2L ri _... �D...--... ! .. r �—...pt9o/��z/ W Owner Address a ....................................................... .......................................... •-•-••......------•-••-..............----•- ----•-••............ --•-----............_.......... p� Installer Address Type of Building �' YP g / Size Lot ... ......- Dwelling— No. of I3edroomsZ/.................. Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of.persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ......................... WW Design Flow---------- ---------------------------------gallons per person er day. Total daily flow Wx l � ..... fow.........-6l.o... ---------------------gallons. �iSeptic Tank furd capacity.1am.-gallons Length/0�� dth.C.Y.".- Diameter...... .•.•--- DisposaNo. .......... V �6Xi� tIV.Z.......... Total leaching area.....l-Z�O q. ft........... dt . Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Lf Dosing. tank ( ) 1, f �` 3�yq a Percolation Test Results Performed by... . t,fj(_,XSl t9.�.S.�t'�f+�.. ...........1 _.._..�.f_.. Date.... _.� _ ?A11�5' /f r...--• ,f H gw� Test'Pit it N�1.../a------minutes per inch Depth of Test PA,.*-.,�i.... Depth to ground water.�sfiw!:..3.2 i� -A Test Pit N•�-2....� .----minutes per incl.t, Depth of '?rest,Pi ........� ��... Depth to ground water.....,c4'�{`r........ -•• ------ - -- ---- ---------- --- - -----------------•--------------------•-------------------•-- -•• fil"-PdORTH-A1d1�OVE off- _ _._ ... O Description of Soil...........:5 f.�.'/Vj�.Y......44D/9.m------------------------------------•----•-- •----. .........-BQARD OF•F9EALTH V .........-••••••----••--•••••••-•-••••--•••-•-•-•-•-••--•---•--.........-••-----•-•...-•-••-•.....---•••-•-•--. ............................... ...... ................................... •-••-•• _.. VW ... ••----•..................................•••---- --....----------....------------......-----•-----..................----................. Nature of Repairs or Alterations—Answer when applicable................... `�A� Ig� ........ . .. ...... -._� -�.__ ._�. - �_...... .. . Agreement The undersigned agrees to install the aforedescribed Individual Sewage Di a"Sy-stt'tn�i h the provisions of TITLE 5 of the State Sanitary 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. Signed.-- •----------•--------•--------------•----•----------:...------....._.......-----•-• ------..... .................... Date Application Approved By.................................................................................................. ........................................ nate Application Disapproved for the following reasons:..................................................................... .......................................... ------------------------------------------------•----- nate PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS _ r I BOARD OF HEALTH ..........................................OF C9rr1ifirate of (lroutfiiittttr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b Installer at...... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the. application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . . .....................-•----............................... NO.......:................. .........................................OF........... .....---- .... . FEE........................ �i�t}ro�Fti �filtirttu C�ott�#rttr#iatt �lrrttti# Permissionis hereby granted--•---------------;......•---------------•-- -•-r----••-••---•- --•••-•--••-••••-•--...-••-•.............•-•...................•---...._.... to Construct '( ) or Repair ( ) an Individual Sewage Disposal System at No. Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated.......................................... i ------------------- ------------------- ------ ------------- •------------------------------------- Board of Health DATE...............................------•------•-----• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS NEW PNGLAND ENGINEERING SERVICES INC . EG�,�� R N�� - 1 X404 OF,NOT,. ANp�VER TORN v;t�TMENT October 26, 2004 Karyl Lipson 131 Pheasant Brook Road Noprth Andover, MA 01845 Re: Title 5 inspection: 131 Pheasant Brook Road, North Andover Dear Karyl: Enclosed is a copy of the Title V report for the property referenced above. The report indicates that the system Passed the inspection. A copy of this report has been sent to the town. If there are any questions regarding the report, please call me at my office, 686-1768. Sincerely, 1; --- ( J I-,' Benjamin C. Osgood . P.E.. Certified Title 5 inspector 60 BEECHWOOD DERIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION .F TITLE 5 -OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: i�3 t ?H rA 44-4- ,a g,ao l�4 9,D �9o�'fM �.rV O e�GR, M,r4 Owner's Name: K AM V. er-o X) Owner's Address: t�J. 11► D Oy C a-* Date of Inspection: .!s/ AD /� Name of Inspector.(please print)-Benjamin C. Osgood, Jr. CompanyName:New England Engineering Services Inc. MaHing Address:60 Beechwood Drive North Andov r, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT 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 Tide 5(310 CMR 15.000). The system: -ZPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: J,e ?A 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 rpt 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. Notes and Comments ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:—IS 1 PIrf1SRwT Btx. ?.Q Owner: Date of Inspection: Inspection SummaryCheck 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[:30-3 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 1 One or more system components as descriibed m 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 4: ND explain: 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: tat PK6#%*N-ti3g44$, C.V Owner: tL.t9�yL. Li-P'' cy�+ Date of Inspection: t p��9y C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health m 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: 1 or is within 50 feet of a _ surface 1mvY water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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,is ,perfonmed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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. i 3. Other: I . Page 4 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: jai Nm iMt Ago Owner: Kr ASI- 41,V6--*0 Date of Inspection: 0 2.p ray D. System Failure Criteria applicable to all systems: You mast indicate fires"or`no"to each of the following for aIl inspections: Yes No ✓' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — tr 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 _ :f Liquid depth in cesspool is less than 6"below invert or available volume is less than%i day flow — 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. — i Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. -AL Any portion of a cesspool or privy is within a Zane 1 of a public well. — -Z 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] (Yes/No)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- You must4ndicate either"yes"or`ho"to each of the following: (The folio criteria apply to large systems in addition to the criteria above) yes no — — the system is with feet of a surface g water supply — — the system is within 200 f tributary to a surface drinking water supply _ the system' ted in a nitrogen sense' area(Interim Wellhead Protection Area-IWPA or a ma Zone a public water supply well ) ply If you have answered"yes"to any question in Section E the system i nsidered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or r 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. Page 5 of 11 OFFICIAL INSPECTION FORM=-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:-A'a) Q N lr A3-4t!' 0-06b A 9.9 t►sb R.TM AtjV 0%3cZ .A Owner: Ki4 L-l?S4N Date of Inspection: Check if the following have been done.You must indicate"yes"or"nor 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 componentspumped 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 now as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? J/_ 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? ;-%eL _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The sloe and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no ✓— 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)1310 CMR 15.302(3)(b)] Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ t 31 Q14665401 u.2oo p, P� 19n AM AnsD dNtQ ^&A Owner:-- ILAA&A t.. L t pGOw1 Date of Inspection: 201 e U ftbWCONDITIONS RESIDENTIAL Number of bedrooms(design):_Lt_ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no):�O Is laundry on a separate sewage system(yes or no):elo [if yes separate inspection required] Laundry system inspected(yes or no):_. Seasonal use:(yes or no)t Water meter readings,if available(last 2 years usage(gpd)): -roo'j j Sump pump(yes or no):_bLp Last date of occ ancca ncy: �� /� Y c —---------------------------------- ------- COMMERCIAIA NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): RDd Basis of design flow(seats/persons/sq%etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meta readings,if available: _ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: p<.,,,,�a _. 4EA ►� �.� Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool —ivy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altanative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: 0�0-TBn1 0%0j L: V00. L R 118 Were sewage odors detected when arriving at the site(yes or no):�c7 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1.31 PHO vW—j gQct�A ILD �a zTk Atip O'AL AAA Owner: 14AIZH L.. t«%FSC)N Date of Inspection: Sq c+j BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction: cast iron V'40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): 1,A J SEPTIC TAMC:_(locate on site plan) Depth below grade: Material of construction: ✓'concrete metal fiberglass polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: t Ser 0 CsA l„to N 5 Sludge depth: Z • Distance from top of sludge to bottom of outlet tee or baffle: I y Scum thickness; t` Distance from top of scum to top of outlet tee or baffle:_ (, Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: S TI c.K Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ?�F0K Int k009 40 LAA GREASE TRAP:A4 ocate on site plan) Depth below grade:_ Material of construction: concrete metal fiberglass___polyethylene other (explain).- Dimensions: 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- Comments umpingComments(on Pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: lal WoR.'i4t AwjD9x,Q4 AAA- Owner: K�1r��L. 61g&C4 Date of Inspection: tat go ay 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(explam): Dimensions: Capacity: gallons Design Flow: —allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc): DISTRIBUTION BOX; (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: O` 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.): -AJ6 1s�y�PC�AlG GR. ovT PUMP CHAMBERyV&(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I� Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: J4i4Ky&' L-05-0m Date of Inspection: t o t 2.0i a Y SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: ✓leaching fields,number,dimensions:1 >�o�s3 �S't X 3 6• overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): PrR.,c'rt Of A6&P A)b&AAAL. N z> V ah+Sy eky u'L G-�E714citi cin. _eto �RtD�.c.rG- t�R nA,�.Q sa,c. CESSPOOLS:QL(cesspool must be pumped as part of inspe ctionxlocate 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 or no): Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.): PRIVY:tj�$L (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.): Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: !a i PH4A9t� 8tzvDn Owner:_ y�{P,Snti1 Date of Inspection: p Y fry SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. DtSfRNcsS i A-TANK 23.3 $ -TANK 3c.2 ' p- six ly'"OJ Cs�A'Lto.✓ 54�1�� 1'/FNIL PLO AS) 4� g 1.(s'ACK Page 11 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 13 t PKO #44'e XP-- jr, j,0 Owner:_ 16.Ik?�1 1.. l..td'S�n► Date of Inspection: SM EXAM Slope Surface water Aid#Jd Check cellar 3;'C /wQ Shallow wells 7 JV-0 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed,site(abutting property/observation hole within ISO 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: sT w� C 5tP.►aT�'P �-(� ASC WL&M GA44wJ01 W.t4�t�Y.l kiL-90W^1oN4 / a•�Y`... o ORTH �IOOVER r MASSAC { + HUSETTS �,pump�119�RKOC 'rd +Sin,�Y �a`v�+ �cT.t , �'h:�+d�`� }�JSrS f J G'fy , �'+r, c, •. 7R-- a ....,� GP hai prov(ded this form for use by local Boards of Health. TheC L in R cor must submitted to the.localBoard of Health or other approy(ng authory700 >. r A Facility Informttlon . O N OF NORTH ANDOVER r HEALTH DEPARTMENT ;�r7+when f�un9 out 1 System Location :�; only the tab key to move your : �-�� •L��,C�� cursor, do not - use the return j CltyRown State Zip Code r, : IMOwnar• Name i' S. Address(If different from location') e Clty/Town State olo P. Te Number Telephone N er .r Pumping Record �. ,a • 1 Date of Pumping Date 2. Quantdty Pumped: — l �.. P Gallons 3r f Typo of system, ❑ Casspool(s) L�Se tic Tank P ❑ Tight Tank ❑'Other(describe); , a 4 ; Effluent Tea Fiiter present?..❑ Yes, to If yes, was if cleaned? ❑ Yes ❑ No � Y Sr Co0diflon of 3yst m,"' 601 �• Sy em Pumped Byr' C-1 Ucenae Number �ti+„e�rrrY'\tio4ltJ1df'�z4�i�� '.t�l�� rir� ' �• AW ,�y,/� 1 r + 'S{ry rl�.wf ' �^"�'�ryy t )r .'r111,t',C hF�I)1 Ir v: I .✓ r .� ,l -•', ' lil i:.,• t.rli r,�'f'/�•lrr�,J,f 1y�. Ir �4A'� .Ar'' - .. r, ,,,\A�Wfj'4 t ��; 7, .Location where.contents Wera.dl;posed: , 1 y w.,• � Z�F�. ljL Date (/ �'✓ http://www.mass:gov/de' ater/approv4is/t5formsrhtm#Inspect t t5forrn4.doa•08/03 System Pumping Record Page 1 of t } a.,, '•,:, ,.. .r,., MAY U OEP.ha i piovlded ;hlivlo/m ror e o 6 2009 ov + :dnll ocvl 6oarcI We.. .^ fivd to the Ioc�l 8oarc: rr moa to S T A, Facility In(orp) cUon MENTI , ..��/�•.r�,� �. SE'S'•°,^� IoGBUon: 11 7To,m ,.;� , ,,I ', ,.,;11.1•,r: .�;Syalem,Ownar,i �r' , , . , , •� r �drµ4 (114V(►rI turn lowUcn) cbb • T��p9�on, n m0�r — ' g,.Plumping Rekord �. OV( o! Pum➢1n9 /f 106 3. Type p! ly)(sm Co99�oo1(y) $apl!C Tangy a, Fmuon( Too, FII(o(Plp,�onr7 Q Yv9 Q n'o ',, `c '•,`; y�l�+ If y69. 18) ': c'oan n — :'r►, All 6•,l"Co�dl�lon'Q(:9yt, m,°'.r,'. ' — y „- �•.. Sy � tim od 8 , �1NV1 ' Gd 11 ►► h•'-" ►, _ 1• ..,'1;�. loca on.Yrhai�'gorjlenU{Were dlyposav: •�••;,:/�'•I�! ••«„,�,,�' :ill '; �lY "• ` l maga.govlda^eleilepp(oYeJallblorm�.r .o 1 - •ai c "�3"4.ixid....Ld.ti.: S� ..i.:. {Y >I^, �.rL•�, I � -' r �� • Commonwealth of Massachusetts Ci /Town of NORTH ANDOVER MAS System.Pumping Record r r 4 ,uL 7 2010 DEP has provided this form for use by local Boards of Health ��IIP� d►�I ord must be submitted to the local Board of Health or other approving utl H DEPART E T .A. Facility Information Important When filling out 1. System Location: forms on the computer,use only the tab key Address to move your cursor-,do not irl cw c� 1ACK. CI /Town use the return tY State key..." Zip ode System Owner. oe Name Address(if different from location City/Town State Zip Code Telephone Number B. Pumping Record r 1. Date of PumpingDate / 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6.. S stem Pumped By: C me Vehicle License Number Company 7. Location w ere contents were disposed: Stri toof auler Date http://www.mass.gov/depAvater/approvalsA5forms.htm#inspect •'_- t5form4.doc•06/03 ".• System Pumping Record•Page 1 of 1