HomeMy WebLinkAboutMiscellaneous - 134 CROSSBOW LANE 4/30/2018 134 CROSSBOW LANE
210/106.EW204-0000.0
Address ( , 1� CPO ss fg6W Title of Hie
Date f=ile Open:
Rage of
Date file closed:_
Doc Document/Action Title Date of A _
action Refer to other Purpose of l�ocuntecnt/A nand notes
Num. Document/ doeunuent/ ----
Action De artment
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Board of AP-peals — Board of Heal h Planniin-g.Board ; Con
seruatiion Commission — Building Departrnen;t--'--
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TO: NORTH ANDOVER, MASSoy 4 19
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
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This is to certify that I have inspected the construction of the said disposal system at
L—n 3 (?Ross- bow /14lv, North Andover, Mass.
SITE LOCATION
The grades and construction are as specified inplans and specifications dated
REy 9— /2 19g�_. by NEVE 116S0C1a7-,b;-S
CCPV, N
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eg. f? FX3n,eerjReg; anitarian
Board of Health BSPTIC SZSTEK
North AncjovarZHaaa.
INSTALS,ATICK*CHECK LIST LOT`'J ``�
ovEn
DATE,
DXI PSOPED EXCAVATI
easpnst
nn OK
wArZ /
""' mer
1. Distance Tot 7-0 8 e; R6�%*o f`o
a. Wetlands
b. Drains jam,
c.. well4` �w. ir.°,p 1 TO
R O iA' ,
2. Water Line Location A . ,.. ,.._ ._._,.
7T
3. No PPC Pipe
?�. Septic Tank
a. -Tees --Length & To Clete Ont Goners
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
/ p
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. - Leach Field or Trench
a. - Dimensions
b: -Stone-Depth
c. Capped Ends_
d. Clean Double Washed Stone'
?. Leach Pits
' a. Di.mensi s
b. Stone epth-
C. Sp sh Pads
d. s
e./Ce=n t Pipe to Pit - Both Suedes.
tj: Clean Double Washed Stone.
8. No Garbage Disposal
' Anal9. na1 Grading Inspection
10. Barricading Covered System
11. As Built Submitted
_ a. Lot Location _ -
b. Dimensions of System
c. Location with Regard-to Pere Test
d. Elevations
e: Water Table
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3ard'of Eealth
crth ;,ndov-er,Ya.ss
SUBSURFACE DISPOSAL 'DFMGN CHECK LIST
"LOT # 13 Ceol5s
PROVED DATE DISAPPROVED DATE
ovided: Reasonss /
. �,
f'Lv✓�s !fes` Ol.���" ��
Title V FAIL i
Reg 2.5 The submitted plan racist show as a ndni rm'm:
the lot to be served-area,dimensions lot #,abutters
b location and to tsP ercol.ation tobservation ests-distance tto o s
to ties
location and re p
d design calculations & calculations showing oU�g
��rereA area leaching area
e) location and dimensions of sys
f) .existing and proposed contours
g) location any vat areas tlri.thiA 1001 of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100' of se-,,-age disposal
system or disclaimer
(i) location any drainage easerent.s thin 100' of serge disposal
system or disclair^er-P anning Board Piles
(3 know sources of cater supply within 200' of serge disposal
system or disclaim'
-2-ocati-on--ef sIT-j:Zoposed ,-ell to sex-ve lot_lOJ' Prom leaching facili',
Ij location of water lines on property-1.01 from leaching facijitjF_
I(q)
location of benchmarkdrive- ays
garbage disposals no PDC to be used in construction
profile of system-elevations of basement, plumb, pipe, septic tan}:,
distribution box inlets and outlets, distribution field piping and
otter elevations
may-i== ground jater elevation in area sae-„age disposal system
(s) plan must be prepared by a Professional $:zgineer or other
professional authorized by 1-aw to prepare such plans
Reg 6 Septic Tacks
/(a) capacities-150 ” of flog, water table, tees, depth of tees,
access, pining
(b) cleanout n ool
(c) 101 from cellar va l or inground s-- .--- -g P
(d) 251 from subsurface drains
Reg 10.2 Distribution Faxes
(a) slope greater than 0.08
Reg 10.4 I b) sunp
loo TO vi?,AI o t)(tfL�
�(�,.� y�a-►��'� �I
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Acs�r- y (Jrs
�u�s
absurface Design Check List Page 2
' FAIL CK
-
Leaching Pits
I
Leaching pits are p erred Where the installation is possible
eg 11.2 a) calculations of caching area-ndnim m 500 eq ft
11.4 b) spacing
11.10 c) surface a 2%
11.11 d) cover mat al
e) P'x2� splash pad
f) tee elbow
g) no ends in pipe from d-box to pipe
Leaching Fields
�g 15.1 no greater t an 20 minutes/inch
area-rdnijr= 900 sq ft
n
15.4 e' constructioof field
15.8 d) sarface drainage 2 %
3.7 e) 20 t from cellar -.P-ll or inground s4nnd.ng pool
Leachi n /Ttlenehes -
T 14.1 a) calcul ons o ' eaching area-n n 500 eq ft
14.3 b) svac, g-4 ft min 6 ft with reserve between
14.4 c) dim. uions
14.6 d) construction
14.7 le)�t�ne
3J,-.10 f) surface drainage 2%
Do- ?1 Slope
J/J 'a) slop ex y = to be show-i)
Lb) y/x % 150 = (to be shoe) _
Pure s
g 9.1 a) approval
9.6 b) staid-by power
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SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street No Lot No 3
. Loc/Subdiv. —M'Lt "J. S 1� Pland Owner
Investigator Observer
SOIL PROFILE DATES
1-'Elev 2.Elev 3.Elev 4.Elev
�{ �2°l
0 T 1 0 TP. 2 0 0
1 1 1 1
T S Ties Pits est
2 T G' 2 -- 2 2
31 3 3 3
4 4 4 4
5 Bo�FY J a 5 zow1 tY 5 5
N
'6 w�C1A.� 4� 6 w clay Ua 6 6
7 7 37 7
8 8 8 8
9 9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
PERCO;,ATION TESTS
DATES
Pit Number 1 2 3 4
Start Saturation 13 1A
Soak-Minutes
a • e
Drop of 3"-Time
Dropof 6"-Time
Mins.lst 31' drop �2
Mins.2nd 3" Drop-
Percolation
roPercola tion
h
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
Governor
Trudy Coxe
Seentary,EDEA
David B.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIO -
Property Address: Address of Owner:
Date of Inspection: f�11 s.� (If different)
Name of Inspector: /✓ � �t` f
Company Name, Address and Telephone Number: 7 7 7
�Jlq#v_cv S ? 11G
CERTIFICATION STATEMENT 12
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, acmrate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper functiort and
K maintenance of on-site disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ F 'Is
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing bees
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 shalt submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500
iA�Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS (continued):
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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: k/ JQ -
The following criteria apply to large systems in addition to the criteria above:
The design floe of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection: G-/—/
Check if the following have been done:
Z'P'umping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
d g that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
�A�built plans have been obtained and examined. Note if they are not available with N/A.
_The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
Al system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
',14s, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility o,tiner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Goss
Property Address:
Owner: ,c� sro`j
Date of Inspection: 4/ .7 , tT
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Rallons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):RD
Laundry connected to system (yes or no):1ej
Seasonal use (yes or no):V-P ////
Water meter readings, if available: lw/p;;
Last date of occupancy:
COMMERCIALINDUSTRIAL: / Ll .
Type of establishment: j
Design flow: ltallons/day
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 meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A 16
System pumped as part of inspection: (yes or no)JO
If yes, volume pumped O Fallons
Reason for pumping. t!1 (Wc. /;.,) Ploy's d %AA1ftp
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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: �1 L
Sewage odors detected when arriving at the site: (yes or no)LO
(revised 8/15/95) $
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
/3 U vo
aG
Owner:
Date of Inspection:
SEPTIC TANK: Ye
(locate on site plan) p
Depth below grade: O �,�
Material of construction: _c'� oncrete _metal _FRP—other(explain)
Dimensions: 16v'<
Sludge depth: `
�H
Distance from top of!sludge to bottom of outlet tee or baffle:
Scum thickness: ! /f
Distance from top of scum to top of outlet tee or baffle: U
Distance from bottom of scum to bottom of outlet tee or baffle: of
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:_
(locate on site plan) /
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom n+ -rum t� bottom of outlet tee or battle~
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:!/
(locate on site plan) 1 l
Depth of liquid level above outlet invert: Aj,4, (-rA CL L
Comments:
(note if level and distributer ;1 eGua!, evidence of s (ids carrn�over, evide�n^ce of leakage into or out of box, etc.)�Q Sa L/d S
N P" cet "o
PUMP CHAMBER&
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
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s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION (continued)
Property Address: / G rb s s bO w AJ
Owner: 64->+0 oa
Date of Inspection:Al—
/ ,9_ q 6
SOIL ABSORPTION SYSTEM(SAS):—k--01"
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: ":go X r/S
overflow cesspool, number:
Comments: (note conditi n of soil, signs of h udic failure, level of ponding, condition Qf vegetation,etc.) SCf�t► ���—
1 tG (� /L v r c ..
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 8/15/95) 8
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
03
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation: 5A ow",{
A (revised 8/15/95) 9
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