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Miscellaneous - 133 CAMPBELL ROAD 4/30/2018 (2)
133 CAMPBELL ROAD } ` 210/106.6-0078-0000.0 x Town of North Andover Health Department Date: Location: (Indicate Address, if Residential,or Name ofof'Business) 3 Check#• Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ F'. ➢ Funeral Directors $ s $_ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ 4' ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) ,y Health Agent Initials 1558 White-Applicant Yellow-Health Pink-Treasurer ' Commonwealth of Massachusetts RECEIVED 4— Title 5 Official Inspection Form MAY 23 2006 Not for Voluntary Assessments Subsurface Sewage Disposal System Form TC HEALTH DWN OF O PA TM NTRTH ER Inspection results must be submitted on this form or on the official Title 5 inspection Form dated 611612000. Inspection forms may not be altered in any way. A. Certification Important:. When filling out 1. Property Information: forms on the computer,use 133 Cambell Rd. only the tab key Property Address to move your Roger and Lynn Warren cursor-do not Owner's Name use the return key. 133 Cambell Rd. Owner's Address N. Andover ma 01845 �-- � Cityrrown State Zip Code Date of Inspection: Date 6 Date 2. Inspector: Robert Kimball Name of Inspector R. Kimball Excavation LLC 21 Clifton Ave Company Address Salem NH 03079 Cityrrown State Zip Code 978-375-1011 Telephone Number Certification Statement: I certify that 1 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. 1 am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails El/75ds F rther E�cal ati by the:ocal proving Authority In a is 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. Title 5 Inspection Forms Warren.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 133 Cambell Rd. Property Address N.Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name 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. 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: Title 5 Inspection Forms Wanen.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 133 Cambell Rd. Property Address N.Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced 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: 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 Title 5 Inspection Forms Warren.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 .j ' Commonwealth of Massachusetts Title- 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 133 Cambell Rd. Property Address N.Andover MA 01845 CiEyrrown State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 trust be attached to this form, 3. Other: Title 5 Inspection Forms Warren.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 133 Cambell Rd. Property Address N.Andover MA 01845 Cityfrown State ZipCode Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection 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 11 z clogged SAS or cesspool ® 1:1Discharge 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 q P ❑ ® than '/2 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. ❑ ® 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 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. Title 5 Inspection Forms Warren.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 a Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 133 Cambell Rd. Property Address N. Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection 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. i Title 5 Inspection Forms Warren.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form B. Checklist 133 Cambell Rd. Property Address N. Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name 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? 0 ❑ 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(3)(b)] Title 5 inspection Forms Warren.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information 133 Cambell Rd. Property Address N.Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection I Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: ocupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title 5 Inspection Forms Warren.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 ' Commonwealth of Massachusetts WAN Title 5 Official Inspection Foran ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 133 Cambell Rd. Property Address N. Andover MA 01845 Cityrrown State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5 Inspection Forms Warren.doc•11%2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 133 Cambell Rd. Property Address N.Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: city feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1000 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 48" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 1" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? field observation Title 5 Inspection Forms Warren.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont) 133 Cambell Rd. Property Address Andover MA 01845 City/Town State Zip Code Romer and Lynn Warren 4-29-06 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I Grease Trap(locate on site plan):. Depth below grade: feet Material of construction: concrete 0 metal El fiberglasspolyethylene other ex Iain 9 :) Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): Title 5 Inspection Forms Warren.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 • Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 133 Cambell Rd. Property Address N. Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes 0 No Date of last pumping: Date 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 3" 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.): Pump Chamber(locate on site plan): Rumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5 Inspection Forms Warren.doc-1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 12 of 16 ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 133 Cambell Rd. Property Address N. Andover MA 01845 Cityrrown State Zip Code Roger and Lynn Warren 4-29-06 Owners Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Dug hole to pits and determined hydraulic failure. Two out of the three pits were flooded. Title 5 Inspection Forms Warten.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 } ' Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cont.) 133 Cambell Rd Property Address N.Andover MA 01845 Citylrown State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Inspection Forms Warren.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 i • < Commonwealth of Massachusetts r Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 133 Cambell Rd. Property Address N. Andover MA 01845 City/Town State Zip Code Roger and Lynn Warren 4-29-06 owner's Name Date of Inspection 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. F_ IF1 c A -C - I� Q_( = a� R ® - .� 5 „ A - - '3o' PO fit , 37 ' `t 3L r Cr - S( � - G Li ~ Title 5 Inspection Forms Warren.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 15 of 16 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 133 Cambell Rd. Property Address N.Andover MA 01845 Citylrown State Zip Code Roger and Lynn Warren 4-29-06 Owner's Name Date of Inspection Site Exam: Slope Surface water (�o re- Check cellar Ory Shallow wells r\oy-\e, Estimated depth to ground water: 5 ` Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: N o r gg. r� Ewy-3e ,j s o A You must describe how you established the high ground water elevation: Title 5 Inspection Forms Warren.doc 11/2004 Title 5 Official Inspection Form:Subsurface S Sewage Disposal stem P Y Page 16 of 16 .. ...... Z-10 TS)E1 TT. THE, CO�WONWE .,, CTS . BER.- ITKNOWN'T-H-AT Robert E.' mmball Sr% ; -has s kisfied;alae ep r z Z i�C s .qualifications, as requited and is hereby authorized .to use tho .title CE tT MED ' `TX.E 5' SYSTEM. INSPECTOR as provided in 30 CMR ,.15340. -and S.ectan 13 of Cher 21A of,.the General Lavers.. .sued �y The Departiner t of Envir'onmental Protection. June 12, 1995 #l.Gting Direcior'of thebA16ri n.f VJatei: Pollution Control' � r TO: � NORTH ANDOVER, MASS A `'` G' 19 R,ll BOARD OF HEALTH FROM:\` DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at L ' T 7 C /t MP 0315 L L f2 D North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated OF Mgss JOSEPH ' J v of. gineer/Reg. YKnitarian BARBAG LO Cl) lNo. 464 = OQ°N �S�QNAL S � eAe yl- �ar 7 ZA•NPAK . ed 4 c -5-- 0 le i I1 0 u)6f tai ti �g� gEDRce�n i\GAe. bWELLI 4- 3 SN ow P IT ' Zg� `S,P, . Tr uK , ��e �) tt ` \ J' - TBS DIST. Co��C \ I Q � GST' It' rplO I WA �6r2 3 pIns ol /590' t a.H.l , , 7,z7 ro sALEi`1 sT NAIL ry 'Aj IA1 PDL-- El. °`EE!. 100.00 �gN1�86LC. �C�Av CONCRETE SEEPAGE PIT DETAILS --- not to scale dARYL 46M T7 4.O r w 7 CA1tfIO&e4L ROAD /Va, AIrZDv�. , /4,1 S, Precast Concrete Seepage Pit Access' Cover Tee or 90° Elbow 4 dia. Vent --, 1/8" to 3/8" Stone 4" dia. inlet Pipe � 12 �O G3 n a£35 o 0 o v��od tS dp o a� 3 Q`G o�o� 0 0 0 �� �o a 0 33 ��o —� 0000p� ooh © o 0 0 o pOa©�,bbpo 25 moo°a� DD��D if S�Vb Weep Holes 42,a Scarify Bottom and Sides, of Excavation Distribution Box Filled With Crushed Stone 3/4" to l 1/2" Stone CROSS SECTION t5, j Qo CD 4Z -� if I, II if Jr I D 0 a �p0 42" o000 Edge of, Stone DR's.- W.s.M. PLAN Sheet 3 l� TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS -SYSTEM LOCATION (example: left front of house) /33 0-a4y DATE OF PUMPING: �U S�� QUANTITY PUMPED �� GALLONS CESSPOOL: NO X YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: - I lddress3 Title of File Page of Date File open: Date file Closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ — tWum• Action De artment ------------ Board of Appeals - Board of Health Planning Board _ Conservation C - ommtssion - — -------- _. Building Departn7ent —' l ' TOWN-OF. N THA NDOVEP DA1� SYSTEM PU PINoRECORI) SYSTEM SYSTEM OWNERADDRESS SyS - 'STEM LOCATION us- 9 DATE OF PUMPING: --.---.....—Q(,JANTITY PUMPED: _.J.5_0 777 No -__.._ . YES_ SOPLiC Tank: NU NA PURE OF SERVICE: 08SERVATIONS: GOOD CONDITION FULL To COVER HEAVY ORF-ASE BAFFLES IN PLACE. DEC C 0 7 2004 ROOTS To� LEA "�J,cF CffflP—LD RUNBACK TOWN1 CF BXCESSIVE SOLIDS'.---- FLOODED SOLID CARRYOVER,_.. OTHER EXPLAIN Pwnp-W by 5 4- 7 COMMENTS. ............... 'UN 1 h I'S rKANSFhKUD W SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Descri tion of Proposed Work check all a Ileable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 770 96: Y-36-22 �c71 �� �T' �'"/ ZK Z l�rt�l��L�u:►-t�� 7 !�Il�'SGL �f�`rCrf-�"" SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USS ONLY. Com leted b 1t a licant 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbingBuilding Permit fee(a) x(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Z Check Number SECTION 7a OWNER AUTHORIZATI N TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I12 '{,ry�Ckt!/tw> as Owner/Authorized Agent of subject property Hereby authorize VLJ -to act on My behalf,in all matters relative to work authorized by this building permit application. Si2nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I 1i,CA),Al3 Aiva a.T. ' in as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the.best of my knowledge and belief Prin ne atur. - e Date �T NO. OF STORIES SIZE BASEMENT OR SLAB PD SIZE OF FLOOR TINIBERS 1 2 ND 3 SPAN DIMENSIONS OF SILLS DR% ENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 4" dia. Cast Iron `t�" dia. Solid Orangeburg or Equiv. Finish Grade r-- -- _ E l. '00--f-) 1 /8 " to 3/8" Stone [Foundafion Wall - �a� �" Max �-- - • e �... 12 _ 98 Of3 # ��tio _ ! Cast `TI__ sow .rc t I 3 1 �f vC r o n ^ UT( Tees_../ ; 110 D!� Ll :fj 0 3/4 to l 1/2' Stone ID 100OGal. Sept;c Tank - ��- Concrete Seepage Pit PRO l_E. Water Table not to scale SoI 1 og Test Data Owner Date 11-l y_ 74 /z TU �� suaso,� Presoak is.y�cr to ocotion 9„ to dj t,Ljq Ls, E Tai. Rate M,0:,4Z- AeO,4�3 P - ;0vV' �?pac�e ,area DRN - &K Sheet 2 j�