Loading...
HomeMy WebLinkAboutMiscellaneous - 136 ROCKY BROOK ROAD 4/30/2018 (2) ad 236RDC-KYBRl?OKMAD 210/090.A-0058-0000.0 - -- --- - i III I ro i r j3,� 1'3dcls`y r �. ZWE File No. 242-392 - !h. •' ' (7o be provided by DEOE) Commonwealth ; City[Town Nart-b And it;.1•';j — of Massachusetts i Applicant.,Rorky .Rraok Realty Trust — I,,• Order of Oonditions Massachusetts'Wetlands Protection Act " G L. c. 131, §40. and under the Town of North Andover Bylaw, Chapter 3.5 A & B . From North Andover Conservation Commi ssi•on To Rocky Brook-Realty Trust Rnr1t3z Brook Realty-Trrt s.t ' (Name of Applicant) : .(Ni; ne of property owner) Address c//b Peter 'Breen 770 Boxford strPetAddress c/o .Peter Breen: 770 Boxford Street ' North Andover:; MA, 01845 11orth Andover, MA, 01845 This OrderIs issued and delivered as follows: Iby hand delivery to applicant or representative on (date) L? by certified mail,return receipt requested on (date) This project is located at Rocky Brook Estates', off -Forest S rP The property Is recorded at the Registry•of_EGGPX-Nnrth . Book T� — Page .a 2 9 Certificate(if registered) The Notice of Intent for this project was filed on February 6. 1987 (date) . The public hearing was closed on. March 18, 1987 ,(date) Findings The NACC . .has reviewed the above-ref erenced'Notice of- :Intent and plans and has.held a pubiic'hearing on the project: Based or •the'information available to the NACC at this time,the NAL has determined that the area on which the proposed work is to be done is significant tti the Fbilowing Interests in accordance with the Presumptions of Significance set,forth in the regulations for each Avca Subject to Protection Under the Act(check as appropriate): ,Q Public water supply i$1 Storm damage prevention I@ Private water•supply in Prevention of pollotion' U Ground water supply. . 0' Land containing shellfish Flood control ® Fisheries rr Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. RECEIVE® Important: A. General Information a When filling out MAR 0-18 Zn 16 forms on the computer,use 1. Inspector: TOWN OF NORTH ANDOVER only the tab key to move your Neil J. Bateson HFJ�LTH DEPARTMENT cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs rther E aluation by the Local Approving Authority 3/2/2016 Insp s ignature VDate 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:authorlty, ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address ho*the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �l 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A)' System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. i *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. City[rown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System willass unless Board of P Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which willrotect public health, safety and the environment: p ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated 9 9 wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will.fail unless the'Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. Ej The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts '111 itle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. i ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the.Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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 oroperator of any large system considered a significant threat under Se . g Section E or failed under Section D shall upgrade the system In accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 l" <t� Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'r 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? 1:1 ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 i DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 I I t5ins•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 i I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 136 Rocky Brook Road Property Address Scott Magennis Owner owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal'use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 2 1 Source of information.. Pumped Sept.P 0 5, 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. El Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .r 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 20 Years old, 10/16/1996, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No n Building Sewer(locate on site plan): 5 Depth below grade: feet i Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3"PVC in house, no leaks visible i i Septic Tank(locate on site plan): Depth below grade: 4 feet . Material of construction: Z concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate ❑ Yes ❑ No Dimensions: 10'x 5'x 4' n Sludge depth:de • 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection D: System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 1 dee . Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene E] other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins•3/13 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 'title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: i Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): I Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State , Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal. No evidence of leakage. No evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* I i Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *.If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 136 Rocky Brook Road Property Address Scott Magennis Owner Owners Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers ❑ number: 9 ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 60' 9 El leaching fields number, dimensions: Ion ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 'r 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Cityrrown State Zip Code Date of Inspection D System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Gornmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at.least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately U � pox 1 Icy" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 L I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is required for North Andover MA 01845 3/2/2016 every page. Citiftown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water ® Check cellar I I ® Shallow wells Estimated depth to high ground water: '4 feet I 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: 1/28/1994 Date I ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan El Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. I i Before filing this Inspection Report, ppIease see Report Completeness Checklist on nextpage. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 136 Rocky Brook Road Property Address Scott Magennis Owner Owner's Name information is North Andover MA 01845 3/2/2016 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® .Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 2/25/2016 9:47:16 AM by Karen Hanlon Page 1 r Town of North Andover Tax Map # 210-090.A-0058-0000.0 Parcel Id 14418 136 ROCKY BROOK ROAD SCOTT & BRENDA MAGENNIS 136 ROCKY BROOK ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.63 Acres FY 2016 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until SCOTT&BRENDA MAGENNIS Owner 136 ROCKY BROOK ROAD NORTH ANDOVER,MA 01845 YONCHAK,JAMES&KATHLEEN Previous Customer Inactive 12/27/2005 136 ROCKY BROOK ROAD NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18057.0-136 ROCKY BROOK ROAD Last Billing Date 1/6/2016 3180086 03 Cycle W Active UB Services Maint. Account No. 3180086 Service Code Rate Charge Multiplier/Users. MISCFEE ADMIN FEE 1 1 9.18 1/. WTR WATER 01 ALL METER SIZE 152.55 /1 UB Meter Maintenance Account No. 3180086 Serial No% Status Location . Brand Type Size YTD Cons 34429611 a Active 00 ERT H b Badger w Water 1 1 625 Date Reading Code Consumption Posted Date Variance 12/14/2015., 634 a Ad',al 34 1/20/2016 -44% 9/11/2015 600,= 6ctual 59 10/16/2015 70% 6/11/2015k541 aActual 32 7/24/2015 119% 3/18/2015 509 a Actual 16 4/28/2015 -38% 12/15/2014 493 aActual 25 1/15/2015 -52% '3 9/16/2014 468 a Actual 55 10/15/2014 222% 6/12/2014 413 a Actual 16 7/16/2014 20% 3/14/2014 397 aActual 13 4/11/2014 -23% 12/16/2013 384 aActual 18 1/17/2014 3%e 9/13/2013 366 a Actual 17 10/15/2013 24% 6/14/2013 349 a Actual 13 7/24/2013 -8% 3/20/2013 336 a Actual 16 4/22/2013 17% 12/13/2012 320 aActual 12 1/9/2013 49% 9/1.9/2012 308 a Actual 63 10/15/2012 154% 6/18/2012 245 a Actual 24 7/16/2012 89% 3/20/2012 221 a Actual 13 4/14/2012 -5% 12/19/2011 208 a Actual 14 1/17/2012 -43% 9/16/2011 194 a Actual 25 10/13/2011 13% 6/13/2011 169 a Actual 21 7/20/2011 50% 3/15/2011 148 a Actual 14 4/13/2011 -7% 12/15/2010 134 aActual 15 1/12/2011 -49% 9/16/2010 119 a Actual 31 10/15/2010 107% 6/14/2010 88 a Actual 14 7/15/2010 7% 3/18/2010 74 a Actual 14 4/14/2010 10% 12/14/2009 60 aActual 12 1/12/2010 -17% 9/16/2009 48 a Actual 16 10/15/2009 39% COMMOttkALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 ti I � �A 540 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_136 Rocky Brook _ —North Andover_ Owner's Name:_James Yonchak_ Owner's Address:_136 Rocky Brook._ North Andover,MA 01845_ Date of Inspection 9/2/2005 Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475.4786_ 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 Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority h&,�Fails ) ,: Inspector's Signature: Date: 9/2/2005_ 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. 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 conditionsof use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_136 Rocky Brook _North Andover— Owner:_Yonchak_ Date of Inspection:_9/2/2005_ Inspection Summary: Check A B C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: 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: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_136 Rocky Brook _North Andover— Owner:_Yonchak_ Date of Inspection:_9/2/2005_ 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the manner that protects the public health safe and environment: system�s funchonmg m a p p safety _ 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 must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_136 Rocky Brook_ _North Andover_ Owner:_Yonchak_ Date of Inspection:9/2/2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or —cesspool _No Liquid depth in cesspool is less than 6"below invert or available volume is'/z day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ 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 DEF 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.] No (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 must indicate either`yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_136 Rocky Brook_ _North Andover_ Owner:_Yonchak_ Date of Inspection:9/2/2005_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ `Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes — Has the system received normal flows in the previous two week period? _ No Have large volumes of water been introduced to the system recently or as part of this inspection? _Yes_ _ Were as built plans of the system obtained and examined? i _Yes _ Was the facility or dwelling inspected for signs of sewage back up.? I _Yes_ _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ 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 ? _Yes_ _ 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: Yes no _Yes_ _ Existing information. _Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_136 Rocky Brook_ _North Andover– Owner:_Yonchak_ Date of Inspection 9/2/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_660_ Number of current residents: Does residence have a garbage grinder(yes or no):_Yes_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use:(yes or no): No_ Water meter reading: Yes_ Sump pump(yes or no):_No_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment:__ Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sgft,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 meter readings,if available:_ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped last year,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping: Inspect tank&tees_ TYPE OF SYSTEM X 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:_9 years old,10/16/1996, as built plan_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_136 Rocky Brook _North Andover_ Owner:_Yonchak_ Date of Inspection: 9/2/2005 BUILDING SEWER_X_ (locate on site plan) Depth below grade:_51 _ Materials of construction: _cast iron _X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) 4"PVC to septic tank.3"PVC in house_ SEPTIC TANKS: X Depth below grade:_4'_ Material of construction: X_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:_10'x 5'x 4'_ Sludge depth3"— Distance from top of sludge to bottom of outlet tee or baffle: 24"_ Scum thickness:_3" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc._Pumped septic tank Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of leakage. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal—fiberglass __polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(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:_136 Rocky Brook _North Andover— Owner:_Yonchak_ Date of Inspection:_9/2/2005_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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 BOXES: X_ Depth of liquid level above outlet invert: _0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-Bog level&distribution equal.No evidence of carryover.No evidence of leakage _ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no): Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_136 Rocky Brook _North Andover_ Owner:_Yonchak_ Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: X leaching trenches,number,length:—2 trenches 60'long leaching field,number,dimensions: overflow cesspool,number: innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok. No sign of ponding to surface._ 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 sludge 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 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.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_136 Rocky Brook _North Andover— Owner:_Yonchak_ Date of Inspection:9/2/2005_ 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. Driveway House B A A to Tank=8415" A to D-Boz=103'4" B to Tank=73'10" B to D-Boz=93'4" Septic Tank D- Boz Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 Rocky Brook_ _North Andover— Owner:_Yonchak_ Date of Inspection 9/2/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _8 Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_1/28/1994_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain:_ You must describe how you established the high ground water elevation:_As per design plan_ Tel: (978)475-4786 Fax: (978) 475-5451 BATESON ENTE"RISES, INC. Excavating-Water.&Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 136 Rocky Brook, North Andover Owner: Yonchak Date of Inspection: 9/2/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 4Bae"son Nei Bateson Enterprises,Inc. I gf All df, its :.AHOISIH 380W MIND Jo a 30I0HO M3In3H 6T'So1 99'8 00'0 867.96 S£ 6ZTT 660T. E00Z/8T/60 ET-600Z 8T ZS*6V 89'9 00'0 j, 68'Z6 8T 6601 SLOT £00Z/ZT/90 EP-E00Z LT 89'S9 89'9 00'0 HIS £Z 940T ESOT E00Z/LT/E0 E£-E00Z 9T F ^° 80'85 89'9 00'0 �06'TS TZ £SOT ZEOT Z00Z/LT/ZT EZ-E00Z ST . ,. 88'68£ 89'9 00'0 1 OZ'8LE LOT ZEOT SZ6 ZOOZ/L1/60 £T-£00Z 6T y"• ` 46'69 TZ'9 00'0 9L*C9 6Z SU T06 Z00Z/9Z/90 £6-Z00Z ET 6L'06 TZ'9 00'0 8S'6E 6T T06 L88 Z00Z/TT/60 E£-Z00Z ZT g , LZ-SST TZ-9 00'0 90'66T B L88 E£8 Z00Z/80/Z0 EZ-Z00Z TT ' T L6`66Z jr 9 00'0 9Z'En 6L EE8 6SL T00Z/6Z/80 ET-Z00Z 0T ti POITT 0E'6T 00'0 6L'E0T 8E 6SL TU T00Z/61/90 E6-T00Z 6 STSs 0E'6T 00'0 S6'06 ST TU 90L I00Z/Z0/60 £E-T00Z 8 L8'8E 0E-6T 00'0 4S'6Z 6 904 L69 0002/ZT/ZT EZ-T00Z L 60'86T OE'6T 00'0 LL'EET 66 L69 8b9 000Z/9Z/60 ET-T00Z 9 9L'Z£ 00'0 00'0 9L'ZE ZT 619 409 0002/LT/E0 ARAM S 66'9L 00'0 00'0 E 66'9L 8Z 869 OZ9 0002/ST/90 E6-000Z 6 EL'Z 00'0 00'0 EL`Z T 0Z9 619 000Z/6Z/EO EE-000Z E P 61166 00'0 00'0 . 6T'66 8T L09 68S OOOZ/TT/TO EZ-000Z Z' k 9E-09E ®0'0 ,00'0 �," 9E'09£ Z£T 68S L56 .666I/T0/0T £T-000Z .T EYP U101 S333 H3t13S ' H3I8t'I 3511 IN3HHH0 HOIHd DIMS 3134 # UH HOOHO AH00H 9ET:HH' ------------------- 4' 980081£ :1tt H113W`IHIUH I S3WOP HUHDN06 980081E dHOISIH IN(1000d S/t1 f r ai :s F zl 3 6 d fi; tR syr` a � &411 4 a ' ani'. 64 ACCOUNT HISTORY 3180086—YONCHAH, JAMES & HATHLMETER 01: 3180086 c a• - ROCKY BOOK ') it FEES TOTAL s O. CURRENT �r a 1 2004-23, 12/23/2003 i 21 47.88 0.00 -0� a +C Ix i E Y r_ t g�"�._,1 'civ,:"ted:r�'�,���;.- �' �;. ate_ � f.'����� �• art GOVERN-101 71 A R„ Inbox•Microsoft OL" Mrcrooft Excel PERMIT—, MSN can Mxrosoft Irk„ TI'h►et 10,1,71.55 c< V" 1:36 1' I ® � � c Thursday,Sep 01,2005 01:36 PM Connection Meter Info Work,Order: Readings r,Meter reading Sena[number Oo 13240204= - 1 •Date; , R,eadmg; Consumption '�ariatrorr, Code Posted date ''Note 1412005; 196 15, 23 a 7/1512005 3 12115!2005 181 151 5 a 4!512005, _ _. 512004 166 14, 81 a 111412005' 4' 9/1712004 152 80 -22 a 10/8/211.004 $ 5 6/141 004; 72 56 591 a 01 �1p4 I 6 412312004; 16 19 0 c 5/17/2004 C10 3+ERT 16=19 " . ,._ 7 12/2312003! 1150: 0, 0 n 12123!2003' W' it ' ( I Add tsio �fy 1 , ,u1 6 c �h. x £ Y 4 f � s N `1 Editing Existing Record(1/1 j ► ` ) New Save . Delete Browse Exit wrw.� .�x +.a ..._._...., ,�,�,r, ,�rvY+G"p';r ►'�°�5p�''�,«nu'.�Br"'+�+n.�`�+�-I�.��.,a.+...--�..�, rte`i ' Mnl I0NWEALTH OF MASSACHUSETTS EXECUTIVE'OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER ITREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM llypaU �e PART A �f✓� //� CERTIFICATION Property Address: / �'v CI� / Name of OwIm OF j Address of Owner: Date of Inspection: Name of Inspector:(Please Print) 1 am a DEP approved system inspector pursuant tp Section 15.340 of Title 5(310 CMR 15.000) Company Name: /r ✓)0 tn✓ Mailing Address: --y Telephone Number: e3 Zz 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 12�_Passes Conditionally Passes _ Needs Further.Evaluation By the Local Approving Authority _ Fails inspector's Signature: Date:IZ The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty 130) 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 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. NOTES AND COMMENTS I revised 9/2/98 Paget of II riv Printed on Recycled Paper Jt -10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a' t PART A CERTIFICATION (continued) ; 'roperty Address: C J 1�1r„�. t/ Date o Date of Inspection: �• ,d��!p� ('/'��� c+ />f° INSPECTION SUMMARY: Check A, 8, C, or D: A. SYSTEM PASSES: / !. 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as ;> approved by the Board of Health. r+ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed r= distribution box is'levelled or replaced The system required pumping more than four 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 I revised 9/2/98 Page 2of11 F � .....Y.+^O^..-,:--, P'"^Y +4'?'YiRwv* 4b.. +dam -%tri Y' `-`e-imv. ..may-" ._:�-,a.._.....rw�r.n•y.-�..- tiv-. s.'. s.-.�+. p aisv p �� .ro'4 i"-`W"!- bi! +'�►Vw.�.yarh..-o„r,. ..: t. .:.�.;ak..,S..+tiri r�3sM' r+ ,.a.F�._��-.�.r,-),�',i hri.-.sry'^' 4 { r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM rS" PART A J / CERTIFICATION Iccoontinued)) Property Address: Owner:^ C�f l�hek- Date.of Inspection: 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 110)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 211 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water.supply well. j — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or mote from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER 5 II i r revised 9/2/98. Page 3of11 - �ax�,�^�C,..+r...R-;-�r+ ..�rx•.u,,.. .fit,., -•ar;.tr..4y+,.-..•.,r?��•,r,,...,ra:6.:ta...r-�3r��'�'°'''''.T' *-�r�?�,.• '°'�--Y'�'—n,:Hr v a. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property -36 Address: / T Owner."A / Date of Inspection: / �©j/ r r1 V-06 D. SYSTEM FAILS: ( e� You must indicate either "Yes" or "No" to each of the following: _� 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. t Liquid depth in cesspool is less than 6" below invert or available volume is less than 1l2 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: =�t You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: i 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 11 6f a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local-regional office of the Department for further information. I revised 9/2/98 Page 4ofII I �F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �ij D CIZ y !r IV ' `elv el Owner: Date of.'Inspection: /�G J / l� y.—� O 0 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No Pumping information was provided by the owner, occupant, or Board of Health. Y _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this t� inspection. Y As 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. All 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 tees, 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. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)1 V The facility owner (and occupants,if different from owner) were provided with information on the proper.maintetian"-of SubSurface Disposal Systems. t. revised 9/2/98 Page Sori] ar t ' ,�`�"' 1,s:,(-w"1.1�.-:Fti""S7aty�,].i..,;,.�•t.i+d H w:,.,.�. :.�.;:i:�'4:�'. .. A, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: L/-0� C��,d„�j� �d''r-�(�fti.,,. ,� 4,1 Owner: Date ofalnspection: f f 04 (�,•' u FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d.lbedroo r Number of bedrooms (design): Number.of bedrooms(actual):_ Total DESIGN flow Number of current residents: = . Garbage grinder(yes or no):�V� Laundry(separate system) (y€s'or no); `& If yes, separate.inspection required Laundry system inspected (ye or no) Seasonal use (yes or no):�/U Water meter readings, if available (last two year's usage(gpd)f Sump Pump(yes or no):—Z:Aj Last date of occupancy:,U19,K E' COMMERCIAL11NDUSTRIAL: Type of establishment: M4. 4 Design flow: qpd (Iasecf on 15.203) Basis of design flow 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 s` PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped:� 0- �gallons 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: / Y II Sewage odors detected when arriving at the site: (yes or no)/ revised 9/2/98 Page 6of11 ..-...-.-�.- a....�s�✓+'..-.,•...�.�wl'^6+ar.'�+y."',.-,+.... -...r.+.•+ . vt•. s-t+.ar m.nis,t,,._ � ;i .•.�..,.yty]�*-ti^ea.r- .:+..a -.a-.. a •__ ^r.. 75.1.. �..:Yr.'6 .'.�, f. r'— v ... ... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)Irop / er: Address: ( � Owner: Date of Ietspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_cast iron C. PVC_ other(explain) Distance from private water supply well or suction line Diameter tf Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_ j Material of construction: Crete_metal Fiberglass _Polyethylene_other(explain) If tank is metal,list age— Wage confirmed by Certificate of Compliance—(Yes/No) Dimensions: Sludge depth: r, Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: r Distance from top of scum to top of outlet tee or baffle: . Distance from bottom of scum to bottom of outlet tee or baffle: r' III How dimensions were determined:- I r 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, II evidence of leakage, etc.) / S 4 7 A H41 C1$l3 f 0 GREASE TRAP: (locate on site plan) / A. Depth below grade- Material of construction:_concrete_metal Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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 9/2/98 Page7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -'roperty Address: 136, ",2" Owner: Date of Inspection: G .�& TIGHT OR HOLDING TANK._"(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) f Depth below grade:_ Material of construction:_concrete_metal Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present ' Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: !� (condition of inlet tee, condition of alarm and float switches, etc.) iP (i is DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invertiOf- / Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) i Pumps in working order: (Yes or No) Alarms in working order(Yes or No) I Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) I: i,. 4 revised 9/2/98 PaFesoftl '�`Ssi,i�A. .v7.. w4 ;...M,ri�.`ti�/"11`�-ten a-,.+ -g�+h"Vr+�..+6t+w.u+A.�;d7+rbuwc.P+^++�---:�..........�•-w....--,�. , -.�_..�..��r - +r.. -y�4..+a.-- - - � � k 4 . . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'roperty Address: / t� �f �� f `✓ U e A )weer: ,r f Date of Inspection: I� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I m 'I Iv �1 t 4 'III i 13.3 ; l revised 9/2/98 Page to of II a r_ NEW ENGLAND ENGINEERING SERVICES INC August 31 , 1994 North Andover Board of Health 120 Main Street North Andover , MA 01845 Attention: Sandra Starr Dear Sandra: Yesterday, two septic plans were submitted by this office. The first plan is for Lot 5 Rocky Brook Road , which is a first-time submittal for that lot . The second plan is for Lot 16 Rocky Brook Road , and is a re- design. All of the items .you pointed out in the first letter were taken care of. The deep water , as you may recall , was not located properly on the first plan, but it is located correctl this y on plan under the system location. This should satisfy all of your concerns. If you have any questions, please calla Yours truly, Benjamin C. Oggood , Jr . 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 a r�i n.£,�.-r r� '4 r���t.g, t..? � ��� � + y°,� '` .;x '� S � � t r � � �:•- E at a R�+r.�,d y�r9'� .f1x1 ., ua -�'" £ tit us y - "'"•i^ i� a f h d f a t t r E t. 5 �C i y t y • t .f 4 T t. ''� i.F } � ¢ � }. t - C # 1. r 1t � :�. 4y\ •s a a '� x'., s�Faf sro h a4 � r ,ys ^3• z c x �"., f .�-3 Taa�.a t{•"v. i '�t'x,Y�� .Az �+«, xz "' t �> '-;zY 4 �: r„ E.'# .c � '� �t y,r � ,;s �-s� t s�5,`�'� � 4: '�,t.AA^ �5ty. a .A gr x" e�N '�vv 4. a � ..s-����SSS s£.r5•�a � �� s-'� rJ r x'. �ro r�r .1'� "J` -t r Y�c � L :,�.,� t ^f e s � .{ � r x;*, r • �a t x L �, a s "- n k p. . rf3&.,*� a A- ! � �•'� rte" ' 5.� .7 x �F�t � + r t ^x� � r; T .,,�"� � a 2,.. t '{'� : f'r s, Y r a r,✓� tr a i i c S F r r t I�'n r s.'S s",r r } to� f �'�'� ��` Yi'A�," � � Y.t � '$4::`x A,..S ;�'n C 3_ i t ✓ ��. .� {x4 fA k is y t y' - F � r 1 Form Np 5 �d3 e Town of N�artk��;��a �ver Massachusetts H"EALT, a ti� } +{�t.� r xa* hi � qt�f �. O`4t�• a��O��.{t �•4,.�'v -: wt f.,_ S �:..t'x'My, �t t 1 Fs, 1 t "c. } ,{tQsF�y Y 9Y r rX,�,k�f,.F 5 K'. � O s > ,la �,"h,x�." jr'' �'r:✓ ak4 t;r>i � `�., SugJ . kd� .�•r�•i#` $ � er a'� s~•� � �co 7.f � .Sr de,,ti t t r 'Y{,!� ,..s« � � ,. f �, .,y 1r _ ipe#„ _. �:f s fr 3 t x N� t m s;k DISPOS;AL WORKS CONSTRUCTION PERMIT lh v pp� h (ILantx wei v� � aP i NAME ADDR.ES5 TELEPIIOYWE ?`t f'��S ';f '. Y. { Yi { 4 / t:" �5- iz$a>• ,art Ile spa. .*', r "� �' a >r - Ss, Hd� t.3S ..r>•r fa '� r prfl 3 � - 'w: •"yk`r Mir z zF3 r't X\'�"kyy `xts � ; t f' z fi h t£ Permission isahereby�granted. totConstr�rct ( r Repair { ) 'anFindivriduad Soil Absofption .a�+� �<. �,��Fti�•1i lki � x. � :. � 3't.".� t r w-::et a .;`'c- .. ., .: _ "ti xa.;, r Sewage D�sposai System-as„shown on,the Design�Approvai S S No N qy a r w1. �i r t Tt'y �j j 31� �� 3;�', !B d x 1 t �'ge.i�,�}.r�. �.�..' Ss A S^xr �avh•,e.y S � , y � u5 e t ' H 4 y Y'� sz k ” If h r: ;� c a�+ k � � x t a �„. r .�,.'$;- r � �t s r,.3•. �`, ,s x t .a r } £ �>. �e� q 7; st t� P�r� � K +Y f r �, •g x �u' tv '" d�;cy '�YJ f'+�1`r a`L�s .� �• f.t r .g �-f� 1. < f � y-� ' Yf 4 S kr h at+ d .4 - M '�'-'... 'i-'a .'d 4 S t 4 P 4 �.1 /�,f } �n��/G� � •r a f CHAIRMAN BOA R U OF HEALTH w x xs � ��,pl ...'�" f ♦ Asn; t�.s � .>?� - kyt .i }� �.tf' r c:. �f,'•. S n i y„s1 z � {.t o- 3 ` Fee 1W.c Na. c. s t ��J Y s � �lz F��� pt '7._ �t q.PFJ T4��,•"z�'"s, �� F -'Y �+ 7+ �.y:r�f r}o he's1 v-. 4 f '.° f � � � v7� .. � -(y i� � k'r r f `E ..}+�. 4 1 � At y�.,s ��A j ^' �s t f .3 n� ���` a -� > '•1•--�, ✓ .�, ?`,f t } �.✓ f'n ,+t, '+ 4 Yrx�.,`y � t � �.r, a �. -y y i 4 {'^.,� J,a, -¢ 5 t .a ♦ rna s. 6. ' '''y+:!¢"{`` �,��:. ���•� .a�x{&�r$4�. }k.���,i i� �,�,;�a 1,>�i ' '� aF. ui`a,}�`�Js�i"''G>x, +1 -.r� �'c x`"�:r H.E"�`..tY W' .° wi x - �Sx I •2' '� s � u � ,cf.' � h,fs + � ..Xaic re t 5 � C£ � +'-. x r i. r,,�'r Yrt�;n y7-,�s>F �" ,� � a'S -. t ;+�i� !a rf £•i,'�ap F� a � `zl`4 � i � wx n�L zy v tt, '^ f: 3 ',. cS z t !lsf x. a ,�+", 3«f. a'€ /`�," ><, } 't t '`.,#ir a. �,atry s��i: d t i% ,, �e� t* �r# '� a s, t ' :s•� rr -y � i x .3 ; t.„z, x s t Yids fi .. f •2 t� »F, 1 �cr �- � a t` _-s.� a fi.. a � S ' �! #P sit � a L tir ✓.,. q � y" ^r'r.'>� - � � .x+t - ?..,?L� 1 L; i t -.: ✓r d r r APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: 107 IleG) LICENSED INSTALLER: P�- (re SIGNATURE: l'�' Y/ G --\.. TELEPHONE# 6 07 2 z CHECK ONE: REPAIR: NEW CONSTRUCTION: r� IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes,LZ- No Foundation_ As-Built? Yes No Approval Date: /. BOAR'S QF HEALTH OCT 41996 J Town of North Andover Massachusetts F°""No.z BOARD OF HEALTH Q 19 °• "�� '=�•r DESIGN APPROVAL FOR ss"CHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM `•' Applicant --3<!5W 5 GooA, j P- Test No. .� Site Location Lor cs%v T!oer-v � fa.. ti;• Reference Plans and Specs. /V- ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed }• in accordance with regulations of Board of Health. • CHAIRMAN,BOARD OF HEALTH Fee co• Site System Permit No. t:i�Ce�`,y.�3/ 33�tt .i + Ja�yk,yt`.tiC.k.t.,lr�,}jf 5�y�1y"�'I : > 1 J t} ♦ - `�, - a `� ,r 1• �.:5ttiv„7" y t\.'(d -.t-l'. :�"!�F�t� .t I1 t+?,l� :`i�,_ -f r<1l ?L.�;i �5: 1j 1�• t` s ♦ RE Irk Z` t"t yy,,\ tll ;t'F (._1" .(♦�, ': t.�l--R. i,tc, n ,, � .:�:. t 7 -r4, ,�- .t 4t' _J f�i}f ; `j t;..i.. pr �tL ': {�t\ % l4('rte 4l:.. �ll::Y .-lal c4i 'kc .air t �. } c , a i :�. 11 . max y. %"' 't- :� �.2. I �r c 1 .�• l1 A 1 i ti C w *- �� Com` �a h�4 �� � Z�.r". 1 \' \ � �. �• - � t h¢�rti!�•- a '� � LE' c i i♦a1'!: k �•�•,� ♦ ti' `C ri . , " l 1, 'r �:x�•.k .��;i.ic•.`� z,1�1C ���'- L�y�� �t,.�1.'� �' 1. w,,`r%rti wN;.. t�I 1 ` .�, % +ti �. � % , 1 C ♦t` 5`:+r�. �l i.�r .� '�1l'C'� F � ',.alt , y;b�:,rte.. � r y t c .�. r. �. � � t � ai' `.t.�.>>` } '\. :::•K1w � .,.! '4'\ : :.1- C s r:.• �'l a t;l k`,., 11 ��1 � R,y ` 1•i�4t�la'y„a cL�C tom. a -r,. :� %1 ;''i. 1 t. �S�Zc •.. � �� �, x �1 t�-._ "`...!'•p tF+t..�,v + t.�>�e. 1 ,.� � � 1-_t .. -s. t + ..� t+ ♦ -tl t � �. �_�.2,,t �{,'1 ""Si.�t ate~ �r�, ��.+�1. r -F•, i alt S��,.`�.. T'1 "� ^,,kf t� "� o.>; 4' 2�_ r, � < 4 t ;•�,�� z��:ri \ 1. ;'�,• t, 4�i�' %'r�J 7 �: anriWfS a i �� i 7 < � , % ti , �� b ;r'+r ;�.C a �..3'�?�1.'��k:' � l. .;`��. ;!.,G`x `'�,r�� �A���{���� � }''u��r "1J.., r ,C�` 1 ` :e t_i � i ,.i ''`• x ,.``, -�"•'�'♦�tl�- L t�x� � C n`•t �.w. : -r.��3..yy Y}.;�...,x L �1a'�11 N,`.r k ";•� 1lyf,.� `[y S :i ,%i� + t'?,>t� � i ,�'J 1 't � i:: •iV •ii% v� �,� ✓�"�44�'Si\; .�'�tl l�� �, - �� (' �5� �,�`S �a \�i���C.�..�":�r.L ",k 11...6r�:i�F•lt��C`�t-P�� yl� ty+.. -S �t 11!\V�. ♦ .♦ 4`-.1 .fit ! "� •v. 1, �. `�>3.l"� L •1.�+,�_'%:L..�C 1;E`:xt�'�r .�tur rc�_2. ��lk� c':'. t R„�'�4��,�? ',��. � DATE_ 16111 Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE '`�G PERMIT # 6g'G DATE RECEIVED 8 / APPLICANT -A USGbbD �I,e ASSESSOR'S MAP 90119 ADDRESS PARCEL # yr LOT # STREET ENGINEER �3A/✓I f ADDRESS 33 PLAN DATE _ /o��' REVISION DATE CONDITIONS OF APPROVAL: APPROVED 4---- DISAPPROVED --DISAPPROVED r PLAN REVIEW CHECKLIST ADDRESS , rte , ,ey ���, ENGINEER GENERAL 3 COPIES STAMP z� LOCUST/ NORTH ARROW SCALE CONTOURS PROFILE L,-' SECTION �� BENCHMARK SOIL & PERC INFO_1,,,-- ELEVATIONS WETS. DISCLAIMER-Lz� WELLS & e WETLANDS WATERSHED?,J/0 DRIVEWAY �Elev) WATER LINE FDN DRAIN SCH40 i/ TESTS CURRENT? ci SEPTIC TANK MIN 1500Gt/ . 17 INVERT DROP (/ GARB. GRINDER(+200% EDF) 25 ' TO CELLAR_LZ" MANHOLE TO GRADE c/� ELEV 6y GW 6/� D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET f, 77 - OUTLET /41.6 _ / (2" OR . 17 FT) TEE REQ'D? j LEACHING r MIN 660 GPD? RESERVE AREA r/ 4 ' FROM PRIMARY? L�2% SLOPE 100 ' TO WETLANDS 100 ' TO WELLS_IZ--- 4 ' TO S.H.GW 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25 ' if above natural elev•%`"10 ' if below) BREAKOUT MET? '-- TRENCHES ET? '--TRENCHES MIN 660 gpd c/ SLOPE (min . 005 or 611/100 ' )L,'--�� >3 'COVER?-VENTL-- - SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) i/� IS RESERVE BETWEEN . TRENCHES? L/-IN FILL? MUST BE 10MIN. L-- - 4" PEA STONE?� i ' BOT 6 ,O X LDNG_/98 + SIDE 4,000 X LDNG,4t�6 = TOT (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright 0 1993 by S.L.Stan CAORTH 4 Town of dover No.3 q/ -� K dirt : dower Mass. COCHICHEWICK ADRATED SF BOARD OF HEALTH PERMIT T Food/Kitchen Septic System""fe'64 `e BUILDING INSPECTOR THIS CERTIFIES THAT......................................... ......�J? ....... ........................................ Foundation has permission to erect......;....a.A)F. :. ............ buildings.on ............. la............i?.Q.C_.��.y:.�,�.Q.d..1�.. ou to be occupied as.......................:................................... //tl. .!�-. ........... !4oil.�.�. ... Chimney .. . . .. .. provided that the person accepting this permit shall in every respect 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 � jINSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. IPP6' PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST ELECTRICAL INSP C Ro NZ...................................... .... ...... . .... . .... ... .................................. rvice BUIL G INSPECTOR Final Occupancy Per nit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Finalh No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. FORDS U - LOT RP-LASE 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.<O.� LOCATION: Assessor's Map Number � �-°+ Parcel Subdivision o J Lot(s) Street o ob St. Number ***************.*********Official Use Only************************ RECO 7r NS OF TOWN AGENTS: � Date Approved Z X3I�� Con ation Administrator Date Rejected Comments D Date Approved Z. Town Planner Date Rejected Comments Date Approved Food Inspec�tor-Health Date Rejected J�//, " -) Date Approved /¢ Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date