Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 144 ROCKY BROOK ROAD 4/30/2018
l _ 144 ROCKY BROOK ROAD lad ' 210/090.A-0060-0000.0 t 1 e l MAP # LOT PARCEL # STREET,- '' CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE AlAPP. BY_ _ DESIGNER: V ���'��i J� PLAN DATE.1 GI CONDITIONS WATER SUPPLY WELL WELL PER DRILLER.�._..____..____....__._..:__,�._._..__.._................ WELL TESTS: CHEMhCAL,_` UAIE Af'f"RUV.EU-_.-:_,.__._____ BACTERIA I A I E. (IPPRUVED _..._.._ BACTERIA II DATE Al- UVEll�______.__ COMMENTS FORM U APPROVAL: APPROVAL TO ISSUE YES NO 1 DATE ISSUED BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL - NU SEPTIC SYSTEM CONSTRUCTION APPROVAL � NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DA TE ��G SY&t M�. SIflLL,�ZI QN 4 .i,:., \ - - '. \1'•sa .., ' •.,:.• . ter. -.A �_ :#at..� _-. 3,.i w�f ]_ X - _ =xIS4THE INSTALLER LICENSED? + ,, NO • -:{ r .'., ..ii �. ?.ice' .. _ ..., .' , <. <{y - , , .TYPE_. OF CONSTRUCTION: ,y W REPAIR** NEW CONSTRUCTION: ;. . CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF..APPROVAL YES N0. t (FRO f ' .,�. ,t •- _ y M FORM U) - r ISSUANCE OF DWC 'PERMIT' ; - ES NO � • DWC PERMIT N0. '- 'INSTALLER: de. : BEGIN INSPECTION _ . EXCAVATION .INSPECTION: : NEEDED: < PASSED v' ''�` BY : .:CONSTRUCTION INSPECTIONS ; NEEDED: AS BUILT PLAN SATISFACTORY: APPROVAL. TO BACKFILL: " DATE: ``T BY 6•FINAL • GRADING APPROVAL: DATE HY FINAL CONSTRUCTION APPROVAL: DATE:6131w-by RECEIVED �LN Commonwealth of Massachusetts JUN 10 2014 City/Town of NORTH ANDOVER TOWN OF iGII,1 ,vLrc)vEft a System Pumping Record tiAaT ' , Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: �� � 1(,-\/ on the computer, &ou use only the tab I key to move your Address cursor-do not NORTH ANDOVER Ma use the return Cit /Town key. y State Zip Code 2. System Owner: � 6d Name 1t U renes Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ,_ 15 1. Date of Pumping y p 2. Quantity Pumped: / Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: NYJ System Pumped By: ame Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 �' nature-of'Naule ate Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 NORTH A l ?O`ii`eD '6'6a4O �VLf/'f O SSACHUS� PUBLIC HEALTH DEPARTMENT Community Development Division L RECEI Date: May 8,2006 MAY 10 2007 Address: 144 Rocky Brook Road TOWN OF NORTH=ANDOVER HEALTH DEP Re: Application for: pool Dear: Mr. And Mrs. Haddad, Your application for a deck at has been reviewed by the]Health Department. The application was denied on, May 8,2007 for the following reasons: 1. ❑ Missing information 2. ❑ Passing Title 5 inspection of septic system required 3. X Location of structure not acceptable 4. ❑ Undersized septic system To address the problem If#1 is checked, please supply: a. Floor plan of existing and proposed addition—all rooms b. Certified plot plan showing house, septic system and proposed project in scale If#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine whether it is operating properly: OR b. Tie-in to municipal sewer ` If#3 is checked: a. Relocate the project—Project cannot be located over the Reserve area for the septic system as shown on the As-Built 1600 Osgood Street, North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 1 If#4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Sawyer, Publi Director Cc`. Building Department File 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 1� / /A515UIL"r -VENT / AS BujL-r 0 r / / 2 / � � / / 8Ev✓�1GE s s I d h� y rF t s r/N G / owCLr /NG T / Op CF � Z 3Z i 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION 15.245: Soil Abso trp ion System Siting_Requimments t (1) Systems serving new construction shall not be sited in-areas with percolation rates slower t � than 60 minutes per inch. 2 When recorded percolation w listed i 3 0 CMR 1 .242 the next 1 ( ) pe rates are between those Use n 1 5 x �. slower rate shall be used for design purposes. 411 (3) Surface and subsurface drainage shall be directed away from the soil absorption system. (4) Approval of a soil absorption system in soils with a recorded percolation rate of between 60 and 90 minutes per inch may be granted only for upgrades of existing systems with no increase in designflow. In such cases the soil absorptions stem design shall be based on a maximum effluent loading rate of 0.15 d/s uare foot. Y g g gP 9 15,246: Excavation and Flagging of Soil Abs=tion System (1) .Excavation for construction of a soil absorption system may be by mechanical means, p "(p's provided care is taken to assure that the soil at the bottom of the excavation is not compacted or} smeared.The bottom and sides of the excavation shall be level and scarified.Vehicular traffic Ta sl and parking of vehicles or equipment in or on the area of the soil absorption system should be avoided at all times prior,during and after construction of the system. (2) Prior to the installation of the soil absorption system until receipt of a Certificate of Compliance from the local Approving Authority in accordance with 310 CMR 15.021, the ' perimeter of the soil absorption system shall be staked and flagged to identify the location of the soil absorption system and prevent the use of such area for all activities which might damage the rIE soil absorption system. Such flagging is not intended to preclude the final grading and landscaping of the area of the soil absorption stem. Stockpiling-of materials orequipment P� g rP Y within the area is prohibited. Qj 15.247: AMegate Aggregate shall be required for all soil absorption systems unless otherwise approved in t1, " writing by the Department in accordance with 310 CMR 15.280 through 15.288,according to the following specifications: (1) Base aggregate for leaching structures shall be provided from below the elevation of the .j. < crown of the distribution line(s)to the bottom elevation of the soil absorption system and shall 3 consist of double washed stone ranging from 3/to 1 ys inches in diameter and shall be free of iron particles,fines and dust in place. r ' (2) A minimum of a two-inch layer of double washed stone ranging from Ys to Vi inch diameter $ and free of iron particles, fines and dust in place shall cover the base aggregate to prevent intrusion of fine textured soils to the system. Geotextile fabric may be substituted for the (int ,; minimum`two-inch'layer of double washed stone. n X5:248: Reserye Area (1) Systems for new construction or increased flow designed and approved in accordance with 310 CMR 15.000 shall include a reserve area sufficient to replace the primary,soil absorption system. The area required for the reserve area shall be calculated in accordance with 310 CMR ' 15.242(effluent loading rates),based on the percolation rate in the reserve area. (2) No permanent buildings or other structures shall be constructed on the reserve area. a _ � r # ( s, 4/21/06 310 CMR-530 REFERENCES NORTH ESSEX <4_: REGISTRY OF DEEDS: DEED BOOK 6262, PAGE 38. PLAN No. 12043-8 4FIN0 1 .18.CIO, FND ASSESSOR'S S65'14' 38"W PARCEL ID: 210/090.A-0060-0000.0 cH OF L T 6 . 43, 8 f S.F. COVERAGE: so G TOTAL AREA = 43,688 S.F. 100% i �Fp EXISTING COVERAGE = 1,776 S.F. 4.1% r, OVR EXISTING OPEN SPACE 41,912 S.F. 95.9% o / �8, CIO \ CIV /p �S o t Approximate Location I Septic System Location By Others — 9pF o I s, LOT 5 3`4' ec 7 / 32.4' 2 Story 35,9• Wood #144 3O 5' I ��cA 1Ln IN i L'1 X01 g'� DN ss FD RCS-CKY BROOK ROAD wD PLAN OF ,LANpImes W ' �IQuw NORTH. ANDOVER , MA NO. 144 ROCKY BROOK ROAD 4,ZA. 7 JAMES X BOUGI S. DATE PREPARED FOR: 20NING: RANDA R. HADDAD R-1 PERMIT PLAN. °a'GNED° Ern: MAW RG BRM BRADFORD E N G I N E E R f N G Co . SHEET 1 OF 1 CHECKED: RG 3 WASHINGTON SQ .. REVISIONS BY ewe HAVERHILL MA . 018 ,30 ;PHOIN:F* Fax: _ 04-24-07 RG 40 (978) 373-2396 (978) 373-8021 "'dfbradford.en r®veri2on.net °A� APRIL 20, 2007 """"E Fl`E N0` 122557 REFERENCES NORTH ESSEX REGISTRY OF DEEDS: DEED BOOK 6262, PAGE 38. PLAN No. 12043-8 P/FND 118.00' p ASSESSOR'S S65'14' 38"W PARCEL ID: 210/090.A-0060-0000.0 ;^H OF . LOT 6 43, 8±S.F. COVERAGE: BOU ` TOTAL AREA = 43,688 S.F. 100% EXISTING COVERAGE = 1,775 S.F. 4.1% ,� uP EXISTING OPEN SPACE = 41,912 S.F. 95.97 ' r r� 0 " Co 39 _ N O I°ROPosFA RES6RVf Paas Q9, Elly � O 'O M Q7 Pei . M I i Approximate Location Septic System I Location By Others Be 90, , o__1 LOT 5 33.4. eC LOT 7 / / 4' 2 Story 35.9. Wood #144 3`5. • 1I 4J IJ Go Ln 1� ' I �15cj 0�3 FND R O C�K . . Y BROOK ROAD FND P L A. N O F• LL A N ED 0 of t� N JA11,�s ' NORTH ANDOVER . MA . NO. 144 ROCKY BROOK ROAD 4' • 7 JAMES W. 80U�G4 S. DATE PREPARED FOR: RANDA R. HADDAD 20N1NGe R-1 PERMIT PLAN : BRM BRADFORD ENGINEERING CO_. s"aT 1 OF. 1 °R N: RG RG 3 WASHINGTON S Q . REVISIONS BY HAVER H I LL MA . 01830 Me E 40' PHmc'(978) 373-2396 Fix: (978) 373-8021 04-24-07 RG br®verizon.net °ismL 20, 2007 FlLE NAmE 122557 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: �- SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) Li y U DATE OF PUMPING: -, 2, QUANTITY PUMPED ����GALLONS CESSPOOL: NO ESEP S TIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: s CONTENTS TRANSFERRED TO: �° FJ5/II/�,Uu7 1J: i Dub.3iJbbll 5I LwAt. PAGE Ui JVDr . �N�ver Q•a �+. 1 Jl� dinSt S SEPTIC ,,AmsMICE Na A nd���- 47 RAIIROAD srpmr BRAMMM,, AKA 01835 u•.ul L 978-372-7471 "Mm or Y REPW Flit TM Cpmn f ADER= ✓ �` IS'� �� SrcblC: 6oc� �" 53 S'he,-uloid I'i IV 1 s 4� I o�a ,SS/Q^7 J6ad --------------- d/YMr O"C /q l)e Aa d da it 197 v 1117e �Qaa �d JZ�ne_ i0 7 CSi7 ale �- � �6G� NEW ENGLAND ENGINEERING SERVICES INC TOWN FNOR q u0 EV BOARD OF HEALTH January 27 1999 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT 144 Rocky Brook Road. Enclosed is a copy of the Title V report for 144 Rocky Brook,North Andover, MA. The system passes our inspection. If there are any questions please call me at my office, 686-1768. Yours truly, Benjamin C. Osgood Jrw . .T. President i I 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845- 978 ( )686-1768- (888)359-7645-FAX(978)685-1099 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS k DEPARTMENT OF ENVIRONMENTAL PROTECTION d� ONE W114TER STREET,BOSTON MA 02108 (617)292-5500 U+ 1 TRUDY;COXES Secretap ; ARGEO PAUL CELLUCCI DAVID:B.STBUFS`` Governor Commtssaotter SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ER71FI ION (� i, Q Al,A-K G� Property Address: !yy Roc y gvJ� l� Name of Owner /n � �5 !J 4� , � ���✓�. Address of Owner:_ Date of Inspection: /l/gl/9g Name of Inspector:(Please Rir t) Ca JA 1 am a DEPoved system nspector pursuae to Section 15.340 of Title 5(310 CMR 15.000) eppr Yat n Company Name: Alecv �s+��cr•Jl �iiGrntc/Lrire jt/I.� c ES�.vC. Mailing Address: _ A/Oove2 "/y Teleptwne Number: 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-sitesewage disposal systems. The system: �/ Passes _ Conditionally Passes Needs Further Evaluation By the.Local Approving Authority _ Fails / Inspector's Signature: C,> Date: The System.Inspector shall submit a copy this inspection report to the Approving Authority(Board of Health or DEP)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 report to the appropriate regional office of the Department cKnvironmental Protection. The original should"be sent t0"' w system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS I revised 9/2/98 Page teru A `J Printed on Recycled Pape, :%2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r ' PART A CERTIRCATI/O�N(continued) Property Address: lyY 2vcCc y �jroJl� (L� r ,V_ A.�d[o.JuL DDateeoof Inspection: INSPECTION SUMMARY: Check A, B,•C, Or A A. SYSTEM PASSES: —ZI 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: I 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. 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 . distribution box is levelled or replaced The system required pumpirtg-Tnore than four-times a yeardue to broken or obstructed pipe(s). The system vAl ven inspection if(with approval of the Board of Health): - -- . •. a_....___..:-__..._.._.broken,pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �'-�Y ��� 6.1116 010 ,v. Dawe of «n: 114 Cc e r) 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 DET MMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILLPROZECT THE PUBLIC HEALTItAND SAFETY.AND THE ENIIIBONMW. I _ 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. 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 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. 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)... OTHER ._.. ._ •.___—...._ revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION(continued) Property Address: Y 2oc l3rJ a G, 2S. A). fiN O u✓C'f' Owner: ��IQ rye$ Date of lnspecdw: i�a�96 - D: SYSTEM FAILS: You must indicate either"Yes"!or"No" to each of the.following: I 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 Botird of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into feciiity- system component due tto an overloaded or cleggedSASor•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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50_feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for -coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: Yes No the system is within 400 feet of a surface drinking water supply the system-ie-witWn 200 footeud*owdwnkiwg.water•supplr.••• —• . ---•• -- - the system is located in a nitrogen sensitive area(interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 u r i' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPtCTION FORM PART B fin•. CHECKLIST Property Address: /yy Rocy &DO& RLO Vit/• ANOoucrt i � Owner: Date of Inspection: / Check if the following have been done:You must indicate either"Yes"or"No" as to each of the following: ' Yes l No Pumping information was provided by the owner,occupant,or Board df Health. , .None of the system compoaa=.barwbaen puavped+for.stJeast two aivoaks and7i he-rystem hasA3"0=csiaiagrrMrai-flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. ✓ 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. C _ 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) 11 5.302(3)(b)] The facility owner(and.orxupaaU,1f differaat from.owner).iusta.pruuided.with inrsmation on f i SubSurface Disposal Systems. revised 9/2/98 PaB e$ortt s< Y 4r� �r�P„�� SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM i 3^ PART C SYSTEM INFORMATION4. Property Address: /yq /?Oc � 92bola N" A,t;,00 a Owner: l'l�ue. f:5 28Es Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d;/betlroom. Number of.bedrooms.(design): Number of bedrooms(actual):.H I Total DESIGN flow Number of current residents:—L Garbad.e grinder(yes or no):jV Laundry(separate system) (yes or no);IZO; If yes,separateinspection•required ` Laundry system inspected (yes or no) Seasonal use(yes or no)-,A/ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): Al Last date of occupancy: .o�! COMM ERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd (Based 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 PUMPING RECORDS and source of inforrAation: System pumped as part of inspection:(yes or no)_ If yes,volume pumped: 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 / Q APPROXIMATE AGE of all components,date instaNed4if known)-end sou►ee of•iwformation: -•3 `t �•- Sewage odors detected when•arriving at the site:(yes or no) AZ revised 9/2/98 Page 6ortl N _w . A2 e* h,e y' • V 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTrON FORM. PART C SYSTEM INFORMATION(continued) ; Property Address: A&4k i Owner: Date of Inspection: BUILDING SEWER: a (Locate on site plan) ;. r Depth below grade: Material of construction:_cast iron V140 PVC_other(explain) }} ' Distance from private water supply well!or suction line Ao"e �« - Diameter Comments:(condition of joints,ventinof leakage,-etc.)L =s O� O2 a an SEPTIC TANK: (locate on site plan) 4 Depth below grade: Material of construction:f ncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is(petal,list age_ Js.age./confirmed by Certificate of Compliance (Yes/No) Dimensions: /S'JU r,.*Ile, .S Sludge depth: "3', Distance from top of sludge to bottom of outlet tee ortmffie: 310 - — Scum thickness: tom•. 4 Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: /0' How dimensions were determined: AA .,sure ST/G/A, Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles,depth of liquid level in relation to joutlet'invert, structurowntegrity, evidence of leek a.etc.) N l ti �114e Wew' COAvD T7O.v, `'vrc.ter Y 7•'fc GREASE TRAP._/V,,+ (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: (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.) i revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address; /y'y :1?,c& ,aauo//, Ro V #,V00, d Owner: M,Ae-4 io�gFS Date of Inspection: r r r TIGHT OR HOLDING TANK: i/ If (Tank must be pumped prior to, or at time of,inspection) (locate on pite plan) 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.) DISTRIBUTION BOX-_ (locate on site plan) rf Depth of liquid level,above outlet invert: Comments: (note if level�f nd distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) -— Oi'4 I n /I U c tie tiy (0^d'(7 0.1. PUMP CHAMBER:_.&tf (locate on site plan) . Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) i revised 9/2/98 Page 9oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMy i PART C SYSTEM INFORMATION(continued) a Property Address: /yy 2ccAy t;320oK fes, /t/. f1Naoaa_ f Owner:! 114,UC Gc t Date of Inspection: -.- �,�a/�98t SOIL ABSORPTION SYSTEM(SAS)- (locate on site plan,if possible;excavation not required,location may be approximated by;non-Intrusive methods) If not located,explain:, { Type: I leaching pits,number:_ �. leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: /1P.i lS / 19e y W i 19 AF leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) /L°" dF S Y"S re 1111 it/c/2�'tfI� CESSPOOLS:iVr4 (locate on site plan) Number..and configuration: Depth-top of liquid to inlet invert: Depth of.solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) o Comments: (note condition of soil,signs of hydraulic failure;-level of pending,condition of-vegetation,etc.) -r PRIVY: (locate on site pian) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE;DISPOSALVYSTEM INSPECTION FORM — PART C SYSTEM INFORMATION(continued) Property Address: yy /1oc. > 13/LDoIA, QcQ, �V- 1 ,,J ave flz Owner: ,rt,k e w Re 15 Date of Inspection: ii/zr�9g SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to`at least two pertnanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) W J M 4 �h 5sS' revised 9/2/98 Page 10 of 11 p 9UBSURFACE SEWAGE DISPOSAL SYSTEM"INSPECTION FORM h PART C SYSTEM INFORMATION(continued) Property Address: 0/bJK 0,0 '/ 19^l 00✓e'e" A4 P1 Owner: iY1 (�ci2B ES. Dave of knspection: NRCS Report name sr� �fy /V1Gc5Sc�c�.,se 4S Soil Type— Typical depth to groundwater �> 6,0 USGS Daae website visited Oaservation jWells checked Groundwater'depth: Shallow Moderate ) Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater J12—Feet Pleaseindicateall the methods used to determine High Groundwater Elevation: V Obtained from Design Plans on record . "Observed.Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions j Checked with local Board of health Checked FEMA Maps' Checked pumping records Checked local excavators,installers ✓Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 'J� �S��/y� ��Y�S ��'CW i�f"il"i- Gt,� 1O` ��`'✓ d� v�ci�� SJ 1"1�7.CC� Du,SPvnw� (�ocS yto� 1'IGc� c� S�r..p �uw.Q G.�}L �S ce,� �eL W S �•1�.�C R.�^fliL O ,SPD . r SKS�I�YL revised 9/2/98 Page 11 of 11 ToVM 0Northover North Andover, Mass., 19 it BOARD OF HEALTH P RMIT TO BUILD Food/Kitchen 4"p f Septic System P r....,.. r�_�•' � �y. 7�1 � BUILDING r BU IL DING INSPECTOR THIS CERTIFIES THAT ...(.�� G ......................... ........ .... . .'. Foundation has permission to erect........................................ buildings on ..4 ... ........... -....'........... .... ... .:. � c� ough V- t �?�=. t' � sto be occupied as........................................................................................................................................................................ 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. t,,,:�dii, , PL BIN � PE�� 7 FOR f 0�J('�aGH,���� ONLY VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULA[Irii BY F`RA. It .S S. O.0 yg Final UTE EEE I'A!3 ELECTRICAL INSPECTOR 'yxService.) �"�....'-� BUILDING INSPECTOR Final 9 GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT 11 AA�� ��Z7Yj Burner PLANNING FINAL CONSERVATION N�� FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT DIVERSIFIED, CIVIL `ENGINEERING CERTIFICATION' Property Location: -Lot' 6, .,Rocky,.. Brook Estates Town /, `State:: North Andover., MA: `Plan Reference DCE; D.wg. No.. 1027 1;, Peter. ,G. Parent; a Civil Engineer, :duly': Licensed Fa,s'::such ; 'n thea Commonwealth of Massachusetts ,'' hereby certify that., I°have personally inspected the,. .. constructed subsurface .sewage. disposal, system .shown on the referenced, plan, and. '. ,futther certify that the; s stem' as constructed enera'li ' conforms - Y 9 Y „ within acceptable engineering tolerances, . toIthat. of the record. -p:lari •. '(see note 1 . ` on paan)`, 'and complies-. with the requirements set forth. in 310 CMR '15'.00 -00FPETER GNB Y 37846 s r `Peter G. Parent 359,bifletoh.Road, Westford, MA .`01.866- (508)692=0939 PA. Box 880, Methuen;MA' 01844 .(508) 687-7161 Town of NortK Andover, Massachusetts Form No.s BOARD OF HEALTH NORTH C ` _ Of 1994 3? p L F A � '�•.,,-o��'`� DISPOSAL WORKS CONSTRUCTION PERMIT �SSACMUSES - Applicant \auzv-\ -C)—C'QaM-A= NAME AUDRPSS (� TELEPHONE Site Location TRnr ((--j Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. cHAIRMAN, BOARD OF HEALTH J� Fee r� D.W.C. No. (-'Ct S' FORM U - IAT RELASE 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. *************n***A/pplicant fills out this section***************** APPLICANT: 2� �� �u�-+�� Phone LOCATION: Assessor' s Map Nu..mber ' l7 Parcel Subdivision 4c Lots -� L Street- Cc, (,: �,c:�, � I� Q St. Nu.i Of_�c�al Use On� � RECOMMENDATIONS OF TOWN AGENTS: Date Armroved Conservation Administrator Dame Reject_.. Cc=e*;-s Date Arnrcved Town Planner Date Rejected Co=enms Date Annrcved Fccc _nspje=Cr ealth Dame Re: ected Date Ap. rsve.d Sept'c Inspec - ea_} Dam=_ Re;ecme_ P,:hc wcr�a - serer/warner connection=_ - drivewa:• pe=4 - F_r e Denar mer. Recs ved by Buildina Inszec=or Dam=_ DATE 1� 7 Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE 7 `L PERMIT # DATE RECEIVED APPLICANTS 06640b, J ASSESSOR'S MAP ADDRESS PARCEL # l� LOT # STREET # ENGINEER IU. �/l!G �� s�'� ADDRESS PLAN DATE A5 �, REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED " PLAN REVIEW CHECKLIST ADDRESS/ ENGINEER _ GDa� GENERAL 3 COPIESSTAMP LOCUS C,-' NORTH ARROWL� SCALE CONTOURS L--` PROFILE L--- SECTION BENCHMARKSOIL & PERC INFO ELEVATIONSC- WETS. DISCLAIMER WELLS & WETLANDS ,_� WATERSHED?Ji DRIVEWAY �Elev) WATER LINE FDN DRAIN ,_ SCH40 TESTS CURRENT? Mq'5 SEPTIC TANK - / it MIN 1500G . 17 INVERT DROP —" GARB. GRINDER(+200% EDF) , 25 ' TO CELLAR MANHOLE TO GRADEELEV_LL— GW 6 D-BOX SIZE ,D/3 7 # LINES�j FIRST 2 ' LEVEL STATEMENT INLET r/ - OUTLET/46),O = 7 (2" OR . 17 FT) TEE REQ'D?AL LEACHING MIN 660 GPD? RESERVE AREA 4 ' FROM PRIMARY?k 2% SLOPE v 100 ' TO WETLANDS 100 ' TO WELLS 6_---___4 ' TO S.H.GW °— 35 ' TO FND & INTRCPTR DRAINS L,-- 3251 TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER 1�1 ' — (25 ' if above natural elev 10 ' if elow) BREAKOUT MET? TRENCHES MIN 660 gpd (/ SLOPE (min . 005 or 6" 100 ' L" >3 'CO ?- / ) VER. VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) ✓ IS RESERVE BETWEEN TRENCHES?Z& IN FILL? MUST BE 10 ' MIN./r\Y/ 4" PEA STONE? T BOT X LDNG /�+ SIDE 3Zb X LDNG WL6 = TOT 7� (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright 0 1993 by S.L.Starr PITS MIN 660 LEACHING MIN 1 (131x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W) xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE . 005 BED/TRENCH (Bed max. 60 ' X 601 ) MIN 13 ' X 16 ' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 660 GPD C, 900 ft2 BED 4— PERC RATE FASTER THAN 20M/IN4--- GW MIN 4 ' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? IST LINE SLOPE . 005? k--�>3 'COVER-VENT SCH 40 �MIN 12" COVER C./ RATE LDG /. S X 6 6 0 _ // 'E /Z,00 = TOTAL (�106e ft2/G REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY 9Pm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME 9Pm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH Copyright© 1993 by S.L.Starr »: Fyyi Town of Nort A dover, Massachusetts Form No.z • f NORTM BOARD �F HEALTH A DESIGN APPROVAL FOR ,ssACMUSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 8&,4) 56006 Test No. Site Location_ G Y --B•toQC Reference Plans and Specs.® 6A/6• 62JG - • 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 r LFee-q'�o Site System Permit No. ,�... .,� r,��,.,.:.:i F*:fit<F..`ti;i`'`S,•".p`S;:tit.xq'r:`r.:,.,,'?N'yd,...4•�, � . .. a.Y7ry:�s�,'F,.�Y.j;�";rA° ."q K;k:' -t`>. z.. .:}. ,- „. q.y, dB` 5:� ..•.+e 6'�- � ..�$� r ' 1 a COMMONWEALTH OF MASSACHUSETTS •''.- EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i a DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ti atc.�a�. l Owner's Name: TO, IN OF NORTHANDOVER/ Owner's Address: BOARD� t)F HEALTH . Date of Inspection: /! '"0/ � MAY 2 3 2001 _ Name of Inspector: (please print) J Q�A.? 1, n �'(f t Y1 e e Company Name: 4,, r7-< < E' /C Mailing Address: 6,12 57-^' ¢ Telephone Number: 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.1 am a DEP approved system inspector pursuant t�Sec n 15.340 of Title 5(310 CMR 15.000). The system: Passes c Conditionally Passes r NeedTFer Ev luation by the Local Approving Authority . Inspector's Signature: ti• Date: ^d/ The system inspector shall/ bmit a copy of this inspection report7the PProvin Authority(Board of Health or DEP)within 30 days of c mpleting 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 ****Thin report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form . 6/15/2000 page 1 '' �,`l.,y;;:.',,•t r.i,nti ry.�,, ...,,.-,..xry ro.9:YrsJT`,u,Y� .✓;r+M�kp .;rf ti4'ry�"'Sc'�''ak".Irt 3�✓yiia-��,�»g'�ecR���fi"7"�'.F.'�,'J;?�;+w.li '��'�- +iR.'fF�'"xq .*w,:.,...,.h,„':+'�wn,#i.$+ �'`�N,+K�-34rti7l�.e+"ix'`.`�s�:r,... k�.E: �c4r ""^;"x`� Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: AN Poe-Ke) ✓Op/C ,t�°c� O .� a Owner: Pero z Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 'System Passes: —Z,have not found any infdgn tion,which indicates-that any of the,failure'criteria.described in 3CMR 10 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. L, I I Comments: y I B. System Conditionally Passes: I 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` obstructed pipe(s)or due to a broken,settled or 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 11 . f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION(continued) } Property Address: e0C grn.L Owner: P10nGly, 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 public health, safetyor the environment ,i ;. 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 g 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 I 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 ST,�ic...;... �attas •..rdy.r�"This system passes if the well'water analysis,performed at a DEP cert ifieu�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. z 3. Other: 3 .: -�. _ c^`<y;r' - .x s, •..�. .,..4.-,-. Y,..� :x=1c-;^:1 rvNn+;F.,�.y, .. ,. ,.�r,,,,,,�..q .+.:;a�a.e' .,yi+,..�;:czy:tw.;:atxya'o..s,�,,:y,.;"yy" -Y I'3,.-kyi•! Page 4 of 1 l .x OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS ,a SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address-/l POG( ✓&14 wed Owner: f`4 iC Date of Inspection: D. `System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for ail inspections: Yes,, No _ {Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool t! Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,e�clogged SAS or cesspool a. . V 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 'h day flow t/ Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number of times pumped t/ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within]00 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone l:of a'public well. _ Any portion of a cesspool or privy is within.50 feet of a private water supply well. An portion of a cesspool or r� is less than 100 feet but Y P P. privy greater than 50 feet from`'a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis; performed at a DEP certified laboratory,for coliform:bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal to or less:than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria ekist 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: Al To be considered a large system the system must serve a facility with a design flow of.10,000gPd to 15,000 gpd• You must indicate either"yes"or"no to:eacli of the followm* g: ; (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 1I 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 Y'iLt Y.. 4. yj Page 5 of l l Y OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART B r CHECKLIST Property Address: C Acle dp l 4 D u t,-eC Owner: Pe Date of Inspection: /15 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: - . Yes No' ._ .._. .�_ '. .-., .r...,. - . . � Pumping information was provided by the owner,c]ccupant,or Board of Health _ -4/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) {I 3 _ 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? , 1f0010�_ 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 1/00" Was the facility owner(and occupants if different from owner)provided with mformaoon the proper• ' r; maintenance of subsurface sewage disposal systems? � f ' The size and locatwn of the Soil Absorption Syste (SAS)on the site hays been determined based o Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 71 w h\ 5 my �.a,;,, ,.. .. r.4, +-,;uer,, q:a.:g . r.,grlg4r{. r:-vt%,:�rX: r�:;�".,rnM,:.SSW§;q�"':�tj�•�ig�'l�C�•etkt�;rr �.,:rr., . —.-�r ... iI I Yi Page 6 of 11 , A OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:/qe r/Z &Z- g- eol Owner: AOI-Lq Date of Inspection: 61 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):Aeumber of bedrooms(actual): l DESIGN flow based on 310 CMR 15.203 (for example:,110 gpd x#of bedrooms):l 5 Number of current residents. 3-�.• N r .1 . +. Does residence have a garbage cinder(yes or no): Is laundry on a separate sewage system(Yes or no :_O[if yes separate inspection required] ] Laundry system inspected(yes or no):_ Seasonal use: (yes or no)P Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):/v 0 j Last date of occupancy: 6 C_<,u COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd a Basis of design flow(seats/persons/sqft,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 , t Was.system,pumped as part of the inspection If yes, volume pumped .lei allons How was uanti um e'd determined? f ' N g 9, h P. P 1 Reason for pumping: TYPE OF SYSTEM ptic 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): Approx' ate age of all components,date installed(if known)and source of information: eg rs Were sewage odors detected when arriving at the site(yes or no):& '+o: i Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS YI, .,'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C SYSTEM INFORMATION(continued) Property Address: p � / oo i::�. ,A. Owner: P—erlq< Date of Inspection: BUILDING SEWER(locate on site plan) "r Depth below grade: Materials of construction:_cast iron lzeo PVC other(explain): ' u ,1 --Distance from private water swell or suction line: µ P l y Co lent_(oon cond�onnoV of joints,ventint evidence of leakage,etc.): , I SEPTIC TANK: (locate on.site plan) i Depth below gradej Z /� Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):,_(attach a copy of certificate) Dimensions: Sludge depth: ` Distance from top of sl�oge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: 3 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: iC per. /31e et 5 rt,4_ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): N GO G - F w , 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.): 1 I i 7 i h _ c.a,n a.. �v �^mow,.:M'Fe.�• +rsM`:.�„y.,.,y;P.a,w'ry vD:'rsc s '' �1'• •+f s: ma" m .f x '�,;:,-t'�a mak» � Rr.�S,a ,..,IF`tw kaY#s."�a U�"�«jJ.'$�Fawr:2.� �„.',�fi.�'":F'�'a`r.�irr�X+.A ^q,�t*/7'.,'. ryxkG:awnx-, Wim. •:r rW • ,{i Page 8 of 11 P OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: le 14 CC01 , PCI wd N �.c 4G, Owner: �rq/ Date of Inspection: "D TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: )i ? �_ '..»,. Material of construction c"b1'crete , metal fibergls_polyethyle other(elain): . 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.): 4� i DISTRIBUTION BOX:1�_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): �A Lr r li-e t. /,/f4 'n ®L"-k 2 PUMP CHAMBER: (locate on site plan) z -'fPuin's in'workm order._” es:or no P :- ��u g, ti(`Y ) . F ` Alarms in working'order(yes or no)` A, Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): : ` 'U �n { I 8 . .' ..41 v^fi'•9'4ri'l`C.hre+aV:`. -..�• 'f—. ...... r �. ...*R... bi.,-rvq,,,;w4.p.-,m,tir@&rK�fi;:trva.rnn r, �.,. ,..-•roi�i ",;;'f'i+�r;+,ik�9S3KY.y7.Ea-k tii'^.'ir,f"^i�+:rs' ,�rv>k'kf�T'c's^ . 'e': r ;r;.,. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: I I )eccKj 600(G taw Owner: e Q N.- Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site.plan,excavation not required) If SAS not located explain why YYI.� 'Y. 41Q�= a.p1An'MxY!A1Y.�MW7h�Yfn'#L• Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: 41 , leaching trenches,number,length: / e�� G(//•Gc leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,.damp soil,condition of vegetation, etc.): O �C 1✓�. � G r c. v N Q ca a.d�i CESSPOOLS: sspool must be pumped as part of inspection)(locate on site plan) Number and con figuration: ' . Depth—top of liquid to inlet invert: 1 r Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: w Indication of grounFlwat�i inflow(Yes o o) _a, ; w Comments(note condition of soil,signs of hydraulic failure,level ofponding,conditi$n of vegetation;etc.): . j PRIVY: ate on site plan) ., Materials f construction: Dimensions: s Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): > I 9 .._..:: ,.:,,-•;:..,. . .... . ...... . ...v,.... .._,_.. ... r ,,... ..�vc=:may �rrR+. ,.K. tea,, 4eY'�i." avv5'bspC;vea+'..wEx"-- [Y-.r .�, rn•.Y3c.+�""v'ti+wzt:;f''�;'F'���•Q�'ti"ia .1§ _ t—,,,r .rwg E { Page 10 of 11 l .. +� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' ,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM"INFORMATION(continued) Q� p Property Address: V/ G K of 1,1 ole— P—d /1/0 V av e Owner: `era/G ` Date of Inspection: j I 1 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including{ties to at least two permanent reference landmgks or - benchmarks.Locate'allwells wtthip.106 feet. Locatewheie pub" eater supply eners'the building.', v V n A: Z.. D l ; .,.use ' CE3.- `� G r ,. y 10 �, ....._ _..M. ,� ,,,, .,` t+ ..+^+v :v' Mrc,.r*k,✓ ,. ,..,-x •�,u=• f•t"`W- r � .. r r rq- rvs:, ` �'t�.'Y 1 'µ"5-a'3ujs a':tt}�i'z,'rbC..,+a: u 1. �{.: a::# .:.vs,r..!^+.,-,r...,, .ea•mw ,v.. -v✓....I.C.' mi•a-+.,t+n.s Page 11 of 11 r" OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' . PART C SYSTEM INFORMATION(continued) 5 Property Address: c_JC 1360 i<- ` nn Owner: Re ae-o _ _ Date of Inspection: T6 " a 1 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Ple''asee/indicate(check)all methods used to determine the high ground water elevation: V"Obtained from system design plans on record-If checked,date of design plan reviewed: 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 ho. stablished the high ground water,elevation: 8i o cl r e/L /,j SQ S-e r`e"-,vr- 5 ;1 tea~ ..,.. .,y..'w,:a st.. r uaAl., ..a• rv.. r.•:a i � - n,.i,Yk"°" .. i 11 , Commonwealth of Massachusetts --3 d City/Town of ! OCT 15 2007 System Pumping Record rForm 4 LTO� , N��tiTH ANDOVER kE LT 1-'DE-,;RTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use only the tab key Address to move your ' J'n cursor-do not use the return City/Town ate /Zip Code key. 2 System Owner: Name ISI Address(if different from location) City/Town State V� �Zio-Code� Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): p 9-1q'0 If yes,was it cleaned? ❑ Yes ❑ No 4. Effluent Tee Filter resent? ❑ Yes 5. Condition Qf System: [Qa)j—QA v,,_ r 6. System P m Br. Name V cIe License Number Company 7. Location whey ntents were dispos� Signature of Ha Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1