HomeMy WebLinkAboutMiscellaneous - 140 MILL ROAD 4/30/2018 (2) \ �,
e--
��
,�
1
l
WILSON, C.D.
Mill Rd.
" APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Mill Rd. . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of _ 1000 gales n size. A manhole (s) permitting easy cleaning
will be provided with reem—ova le cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 200 lineal (g9nUS,1J feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe, The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed, A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
Not of the installation will be less than an 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved bre the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE
L11 LAI U,4A �*9,y '(Le12A1
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE i�®d�..e �TZ"/-�
Gc�z- a
Sature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATEio]-
Signature of 'Inhpecting Officer
Percolation Test 4 min. Soil: Sandy-gravel
Garbage Grinder /Yv�
+ I
BOARD OF HEALTH
OWN OF NORTH ANDOVER, MASS.
4/•
so
co
Box
fv
46Y z�
��• Li 'v
J.-
1. NAME 0 W DATE 6/31G L/
2. ADDRESS L ✓�_e .0 LOT NO. TEL./)2, -32 V
3. NO. OF BEDROOMS DEN YES NO X y fr 7
4. GARBAGE GRINDER YES NO k
5. SHOW DIMENSIONS OF HOUSE k qt
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE Tune 2, 1264
NAME OF APPLICANT C• D. Wilson
LOCATION mill Street
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X Repair
GENERAL DESCRIPTION OF LAND
SUBSOIL: Clap Gravel . Sand y gravel
PERCOLATION TEST 4 minutes per inch.
- - - - - - - - - - - - - - - - -
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 19000 gallon capacity.
LEACH FIELD 200 lineal feet of drain pipe.
s ).A L--Jl
illiam J. r' scoll , Engine
Board of Hea h
Of MOFiM_.'�
5429
O
Town of North Andover
HEALTH DEPARTMENT
SAC64U5
CHECK#: DATE:
LOCATION:
H/O NAME:
CONTRACTOR NAME:
1
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
L
�itle5
spector $ � �)
eport $ .�o we
❑ Other:(Indicate) $
AL -
` j
Health Agent Initials.
White-Applicant Yellow-Health Pink-Treasurer
` Commonwealth of Massachusetts �
Title 5 Official Inspection Form e
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
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.
Important:
When filling out A. General Information r7-ECF-IVED
forms on the
onlycomthe tab key uter,use 1. Inspector: - (�11
to move your Benjamin C. Osgood, Jr.
cursor-do not Name of Inspector
use the return HEALTH DEPARTMENT
key. none
Company Name
16 Hillside Avenue, Unit 3
Company Address
Amesbury MA 01913
n City/Town State Zip Code
978-834-6585 870
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9, C— 4-27-11
Inspector ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
z
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
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.
*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):
f i
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner owner's Name
information is
required for North Andover MA 01845 4-27-11
it
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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
El ® 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
J'( 140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
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.
❑ ® 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 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. City/Town 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?
❑ ® 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
600
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
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 holdingtank resent? Yes No
P ❑ ❑
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
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:
Source of information: Not for approx 10 or more years per owner
Was system pumped as part of the inspection? ❑ Yes 0 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.
❑ Other(describe):
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Constructed 1984 Per Design Plans
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5"
feet
Material of construction:
® cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipe under porch and not visible
Septic Tank(locate on site plan):
Depth below grade: '5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gallons
Sludge depth:
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. Cityfrown 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
22"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
181-
How
8"How were dimensions determined? Measure Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank in good condition. Concrete tee intact. Recommend the installation of PVC tee on outlet.
Recommend pumping tank.
Grease Trap(locate on site plan):
Depth below grade: feet
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: Date
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
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:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
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.):
Box in good condition. Distribution equal. Evidence of soilids carryover. No leakage in or out. Box 12"
below grade
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 5-Tx Tx 29'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
i I
❑ 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.):
Area of leach field looks normal. No evidence of ponding, damp soil, or unusual vegetation.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner owner's Name
information is
required for North Andover MA 01845 4-27-11
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.):
I
I I
i
r
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A-2g-►4
i/ rijDX
I j�o &ALLo N
7"dfn�i�
ou4 �
r
W
t tA,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t 140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 3
feet
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: 4-25-84
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
usgs maps
You must describe how you established the high ground water elevation:
System elevation is very close to the ground and was constructed in an area which was raised.
Typical water table found in this area per inspector experience is 3" USGS maps indicate Paxton Soil
with >6'to water table
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
140 Mill Road
Property Address
Sandra Knox
Owner Owner's Name
information is
required for North Andover MA 01845 4-27-11
every page. City/Town 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
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
COMMONWEALTH OF MASSACHUSETTS
TOWN OF N.ANDOVER
SYSTEM PUMPING REPORT
, � �� "
NAME OF PUMPING COMPANY ���(�'a REPORT FOR MONTH OF
CONTENTS CONDITION
OWNERS GALLONS *H. G TRANSFERRED OF
DATE ADDRESS NA14E PUMPED ' C D S TO SYSTEM
- - C4 C c - mrd �) 1 5 sir '1
9e=CCS i0 \1r �►� r Sri"
torr �c�l ��c cC
0�_ - m r`mow S Z l
Ln
BOARD OF HE;k'LTFllll"
JUN 10 2002
PATRICK J. DONOVAN ASSOCIATES, INC.
elacm and XOSS Adjustments
P. O. BOX 110
WAKEFIELD, MA 01880 -
TEL. (761) 245-5540 — FAX (781) 245.7016
April 24, 2000
Building Commissioner
City or Town Hall
North Andover, MA 01845
Insured : Sandra Lee & Raymond Knox
Property Address : 140 Mill Road
Insurer : Hingham Mutual
Policy Number : H09807840
Type of Loss : Water
Date of Loss : 4/22/00
Our File # : WAP30877
Claim has been made involving loss, damage or destruction of the above-captioned
property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143,
Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section
3B is appropriate, please direct it to the attention of the writer and include a reference to
the captioned Insured, location, policy number, date of loss and file number.
I
On this date, I caused copies of this notice to be sent to the persons named above at
the addresses indicated above by first class mail.
Vern Laws, Adjuster
VL/jmc
ASSOCIATION OF INDEPENDENT INSURANCE ADJUSTERS
�TION
WDUENDEW
of Massachusetts MRAMM
i.,
COMMON\t'EALTH OF MASSACHUSETTS
EXECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRO`N'MENTAL PROTECTION
1
ONE WINTER STREET. BOSTON, NIA 02-108 617-292-5560 I
TRUDY CORE
w1LL1A*,!F WELD Sccrctan
Govcmo:
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Gov or SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
cm
PART A
CERTIFICATION
Property Address: l�>Q Address of Owner:
Dale of Inspection: 8/a��/%� (If different)
Name of Inspector: BENJAMIN C. OSGOOD JR.
1 >_m a DEP approved system inspector pu�suant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: NEW ENGLAND ENGINEERING SERVICES, INC.
Mailing Address: 33 WALKER ROAD NORTH ANDOVER MA 01845
Telephone Number: 508-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection-was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal-wstertts- The system>
+ Passes
'Condrt(onalh Passes -
Needs Further Evaluation By the Local Approving Authority
Fails
--aInspector's Signature: �""'� tJ l , Date:
Ar
The Svstem inspector shat bmit a copy of this inspection report to the Approving Authority within thirty (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 repon 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 authow)
INSPECTION SUMMARY: Check A, B, C, or D:
AJ SYSTEM PASSES:
V I have not found any information which indicates that the system violates any of the failure criteria as dtfinedd in 310 iR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
I
el 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 lof the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes; no:-or not�determiiied`(Y.'N;or•t4D): Desdibe basis of determination in all instances. If-not determined explain why not.
The septic tankis'metal, unless the owner or operator-has=provided the system inspector with'a copy o(a Certificate of
Compliance'Iattached)' ndicaiing 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 i(the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(r•-i•.d 04/25/97) "- p•4. 1 of 10
92-
SUBSURFACE
2`SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
` QCCERTIFICATION (continued)
Property Address: l yQ ��/ �`V/ 111v I" wa,
Owner: -T001 Ale'0a'1Ve4,2
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
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',. Describe observations:
broken pipe(s) are replaced
obstruction is removed
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):
br9ken pipe(s) are replaces
cbstruction is removed
� t
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 B(JARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or pri%y 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 APPROPRIATE) 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 to 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.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more 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
(r.vis.d 04/25/97) P.V. 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
// QQ CERTIFICATION (continued)
Property Address: /,410 /,V,i�401 mw
Owner: --R)e f' 3 t///e4!ot
Date of Inspection:
DJ SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined 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 boa above outlet in4rt due to an overloaded or clogged SAS or cesspool.
Liquid depth .n cesspool is less than 6" below invert or available volume is less than 1/2 day floe.
t
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.
Am• porton of a cesspool or privy is within 100 feet of aIsurface 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.
Am porton of a cesspool or priory is within SO feet of a private water supply well
Anv porton of a cesspool or privy is less than 100 feet bpt greater than 50 feet from a private water supply well with no
— — a
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis for
cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You mmst indicate either -Yes- or -No" as 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:
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 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 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /y0r�G j� /1;0 //0
Owner:
Date of Inspection: A
Check if the followinghave been done: You must indicate either 'Yes'or'No' as to each-of the following:
_
Yes No
_ Pumping information was provided by the owngr, occupant, or 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 during that period. Large volumes of water have not been introduced into the system recently or
�as/pan of this inspection.
As built plans have been obtained and examined. Note ii they dre not availabSe with N/A.
_ The facility or dwelling was inspected for signs of s5wage back-up.
t
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.
f The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different irom owners were provided with information on the proper maintenance of
Sub-Surface Disposal System. +
Existing information. Ex. 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)(6))
(r.vi..d 04/75/97) PA9. 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: e.p.dJbedroom for S.A.S
Number of bedrooms:_
Number of current residents: 2—
Garbage g,-r der(yes or no): ,4v
Laundry connected to system (yes or no):4—/
Seasonal use (yes or no): /to s
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump Ives or no):
Last date of occupancy:& T
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow vallons/day
Grease trap present: (yes or not_
Industrial Waste Holding Tank present: (ves 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:
Aj 7` ;r—
System pumped as pan of inspection: (yes or n;)-Ie,
If yes, volume pumped: 13-4'V
�(rl1 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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
I
Sewage odors detected when arriving at the site: (yes or no) Ak
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ ) SYS/TEM INFORMATION (continued)
Property Address: Ai' 11114, /�'!4twc—
Owner: ',
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade: /a u
Material of construction: ✓cast iron _40 PVC _other(explain)
Distance from private water supply well or suction ltre
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
6.�
SEPTIC TANK:_
(locate on site plant
Depth below grade:
Material of construction: to"'concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age— Is age confirmed by Cendicate of Compliance _(Yes/No)
Dimensions:
Sludge depth: A I
Distance from top of sludge to bottom of outlet tee or baffle:'
Scum thickness: O
Distance from top of scum to top of outlet tee or baffle: S'
Distance from bottom of scum to bonom of outlet tee or battle::�O
How dimensions were determined:/yl �5uP?.rpaK S'�s`c K
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.) 7.1 moo A/-a4, /eOk
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
I
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.)
(r—i—d 04/25/97) P.q• 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
2-SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: frank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design f!o� . gallonJda\
Alarm level. Alarm in working order _ Yes, _ No
Date of previous pumping:
Comments: i
(condition of inlet tee. condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet inven: D a
I ,
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
- .E3 ox O K A-�j (-'!/,o aoce 0 r?
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(raviaad 04/25/97) Paque 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ � SYSTEM INFORMATION (continued)
Property Address: //r/d IW/'11 rQ'• 111,4 �riaboa��L
Owner:
Date of Inspection:
7
SOIL ABSORPTION SYSTEM (SAS):_
(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: s
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:_
overflow cesspool, number:
Alternative system:
Name of.Technology:
Comments:
(notecondition of soil. signs of hydraulic failure, level of ponding, condition of ve}etation22etc.)
01r JIeC/GCS SGOw �JS-G�fS O� ��OB, LiG TIDI�r/Ic/c . �G�%�i*Piiw Uiri/ OC�+7
CESSPOOLS: _
(locate on site plan)
Number and configuration: , ,
Depth-top of liquid to inlet invert:
Depth.of solids layer.
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater: ,
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
I
i
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 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 'y0 14VI
Owner: Z.
Date of Inspection:
Q/yt /j
m-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
I
J
a�
a�
S h 4z 9 7c)A ec l•1
A
� 1
0
Z �
a
(rwiud 04/25/97) Page 9 of 10
9,;7- y�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION .Icontinucd)
Property Address: /y0 /�6 �`"� 0 A41do'eve-
Owner: 3 ASD SIL 13 Ci i��L
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
' s
Observation of Site (Abutting property observation hole• basement sump etc.)
Determine a from local conditions
Chgck weth !oca! Board of health
Chec; FEMA naps
) i
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in .our own words how you established the High Groundwater Elevation (Must be completed)
l �eSt`Giu PLnw Tz ��,'cu«<f�S cQ.,44e —1'(4 L
1 (l r D44y.-),Al 0 4= ��63 Pt C- k
o?. Sa ,r1 /n��� ,�,�,�.�/� l.�sG �-� , f r� �ti rr✓ra�K i��Ll�
I
(r.via.d 04/25/97) P.g. 10 of 10
NEW ENGLAND ENGINEERING SERVICES
INC
TOWN OF NOMI ANDOVER/-
BOARD OF MFALTH
EAT I9f
August 25, 1997
North Andover Board of Health
Town Hall Annex
School Street
North Andover,MA 01845
RE: TITLE V REPORT 140 Mill Road.
Enclosed is the Title V report for 140 Mill Road,North Andover,MA. The system passes our inspection.
If there are any questions please call me at my office,686-1768.
Yours truly,
Ca
Be Jamin C. Os Vod Jr.,E.I.T.
esident
33 WALKER RD. - SUITE 22 - NORTH ANDOVER,. MA 01845 (508) 686-1768
Board of Health SEPTIC SZSTEK �''QI/�j
North Andovnr�Hziaa. j
" INSTALLATIGK CHECK LIST
CVE DATE DIWPRUTED AyAnai 01 FAIL
Re uDnst
FATJ� OK
1. Distance Tot
a.----Wetlands
b. Drains
i Co. Well
2. Water Line Location
i
3. No PPC Pipe
4. Septic Tank
a. _Tees -_Length & To Clean Out Covers
b. Cement Pipe to Tank On Both Sides of Tank '
5. Distribution Box
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 ids
d. Clean Double Washed Stone, :
7. Leach Fits .
A. V nar s ons
b. Stone Depth
c. Splash Pads ' '
d. Tees
e. Cwt Pipe to Pit,,- 13o,t4 Sides
f: Clean Double Washed', Stone
8. No Garbage Disposal
9. .-glp,al Cra.ding Inspection
10. Barricading Covered .SysteM
11. As'.,Built .Submitted .
a. Lot Location
b. Dimensions. ,of System
c. Location.with Regard-to Perc Test
d. Elevations .
e: Water Table
f
Board of Health
SOMFACE DISPOSAL DESIGN CHECK _
- -LOT ';,Ooq
DISAPPROVED DA
APPROTEDReasons: r
Provided.
Title V FAII, r 4
Reg 2.5 Th submitted plan must aho�t as a �ttimt�n+t
e lot to be served-area,dimensions lot #,abutters
b location and log deep observation hoeseeto tiesties V ' : .
c cation and results percolation tests sc
-sign calculations & calculations shm-ng required leaching area
e location and dimensions of system-including reserve area e
'f) es3sting and proposed contours
g) location any vot areas Athin 100' of sewage disposal system or
_ disclaimer-check wetlands napping
(h) surface and subsurface drains within_100' of sage disposal -
system-or-di s claimez'.f - -
(i) location-_arty drainage easements 14thin 7IJ0' of sc-sage disposal
system or -disclairer-Planning Board-files_--
(�) kno= .sonrces of -smter supply xitMh-200! of se ge disposal a
- - system or_disclP..in� _
- (k) location-,of-&V-proposed=-„-e11 to serve lot-100' from leac3�Cig facil'
location-=.ol meter lines-on pr9perty-1. leacbi6g facili
(m).110cationflf
T7-: (n). dritlef =
-(o) Garbage -disposal$— -- - -
(p) no PVC-to be -used in-construction_
(q) profile of system-elevations-of-basement, plumber pipe,: septic tan
= a.,�-distribution--box--inlets.=and:outlets; stribution :field piping -and
0tter elefations -
(r) tn�3 m:aro d_vater-�eleYation.An-area se-,age disnbsal systeia6-_
((ss).plan mast_be=prepared=by-:$ Professional agineer or_others_-
pxr�ofessional_sutborized by 2dx-to prepare such=plans '
P.eg 6. Septic Tariks - - :_ --
(a)- capacities=150 'of-i'lo �=-meter-table; tees, depth o.�_.tees - - -
ry access i
� F�'pn g -.
(b) cleanout
(�) „10' from cellar -a11==or. iugroimd -pool
(d) 251- from subsurfac-e_drains
Reg 10.2 - Distribu-ion-Fbres
_s ope_greater-ai3on;{3�O8.” f -
Reg 10.4
Subamxftke Design Check List Page 2
FAIL OK
Leaching Pits
Leaching pits are preferred where the installation is possible
Reg 11.2 a) calculations of leaching area-adnimum 500 eq ft
11.4 ) spacing
11.10 4e)/il
)/ss rface drainage 2%
11.11 `) cover material
x2Ix4m splash pad
tee at elbow
� bends in pipe from d-box to pipe
Le ichin Fields
leg 15.1 a), no greater than 20 minutes/inch
ti ,area-minimum 900 sq ft
15.4 do construction of field
15.8 el-, d) surface drainage 2 %
3.7 X0,1201 from cellar wall or inground swimming pool
#f
Leachin Trenches -
teg 14.1 077FUcula ons of leaching area-n n 500 sq ft
14.3 b) spacing-4 ft min 6 ft with reserve between
14.4 7 c) dimensions
14.6 - d) construction -
14.7-- - e) stone
U.10 f)-surface drainage 2%
s
_ ,Dot ill- Sloe - ---- --
a). sloe-y x s to, be-s'wwm)
x-.1-50 (Wbe�slio ):__ -- -
approval&� -'- -
9.6 b) stand-by`posrerLI
- t- -
_ _ j
t * t t t t- t r r
- T --'T- + . }• �- 1 -'tT�' I�-r-1-���^w_} l.._.- _d- + ._ -.. .•- ._ Y- .r .,. _ w �. - f � J1 -
vi
14
h - '
I I I
.4.
I
�� I �•� 1 I `i I 1 '
1
r .
I i I I 1 1 I
1
--4--t-
. � • III � I a 1 - -
-r-t -- I I � I I —*---I- -t---�—•--.—_!._�_r� -�1 -+Vr —i"a.`7_�, '-�--+-- T--•�---�--� -t _r ..t _�
+ -+�_�_�.T _•,___-*—_-�----�—'ll• —�,---T-,^•+---ti t i r—-+ + � � I. a--._y .{.._.�.�: U f,� -i--+--t- -
-�' -��--*' -(-�'-f•--}�--f---F�-^r�--"1— t�t r 4 I —i--�^-j---i-'--'h- 1
I
J
j
I
!
f
r �
I
P PATRICK J. DONOVAN ASSOCIATES, INC.
elaim and Foss Ad ustments
P. O. BOX 110
WAKEFIELD, MA 01880
TEL. (781) 245-5540 — FAX (781) 245-7016
I
March 27, 2001
Building Commissioner
City or Town Hall
North Andover, MA 01845
r Insured : Sandra Lee & Raymond Knox
Property Address : 140 Mill Road, No. Andover, MA
Insurer : Hingham Mutual Insurance Company
Policy Number : H09807840
Type of Loss : Water Damage
Date of Loss : 3/5/01
Our File # : WAP32165
Claim has been made involving loss, damage or destruction of the above-captioned
property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143,
Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section
3B is appropriate, please direct it to the attention of the writer and include a reference to
the captioned Insured, location, policy number, date of loss and file number.
On this date, I caused copies of this notice to be sent to the persons named above at
r the addresses indicated above by first class mail.
Vern Laws, Adjuster
VL/mn
1SSOCIATIOA AP INDEPENDENT INSURANCII IDJUSTE
„ssaa„nCH
of Massachusetts ` WOUDew