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Miscellaneous - 1507 SALEM STREET 4/30/2018 (2)
1507 SALEM STREET _ 210/106.A-0208-0000.0 1 r l � l ; 4. I r " � ^ `+ �� ' MAP LOT �— � ���'��� PARCEL ST ` . .._�. _ '_��^ ...__'__ ` ' W—APPBOVAL HAS PLAN REVIEW FEE BEEN PAID? NO ` PLAN APPROVAL: DATE APP. BY DESIGNER: PLAN DATE J CONDITION / . ' ` '. '`. . ...........--- ....................... ` . + � . ' WELL�A��� SUPPLY: . ^ ^ WELL PERMILER T' / DRI/— -----'-- --- ------ ' ' — ' '. . WELL TESTS: DAlE APPRUVED __ — ^|L' ' . TDATE APPRUVED — --_ — BACTERIA I DA7E APPROVED_______ ` COMMENTS: ' ` ` / ' , ` ` � ` FORM U APPROVAL-: APPROVAL DATE ISSUED ............ ` CONDITIONS: ` ........ FINAL APPROVAL: ' ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO ' SEPTIC SYSTEM CONSTRUCTION APPROVAL / NO OTHER YES NU ^ � ANY VARIANCE NEEDED YES NO ' FINAL BOARD OF HEALTH APPROVAL: DATE: _BYc___ ' r 'i i i1` M1 ;F•Ri7j�'' • �` �4dP'1 j•1 r"����°�`f�y 4* + ,�.1. s.IS. THE INSTALLER LICENSED? YES NO Ali r�!! GJ'4 yy, .�1n,SM4+ rr, r r :•' ' r, i! ,.,• * fi;K�' NL W -TYPE OF CONSTRUCTION: REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YE 1�0 CONDITIONS OF APPROVAL YES NO (FROM FORM U) ; ." ISSUANCE OF DWC PERMIT YES 1 NO o DWC PERMIT NO. v INSTALLER:_.—.;_ • tri''?.,�'' ;i�,;. 5: — - ------- —.._.__. _ BEGIN INSPECTION YES 0: EXCAVATION INSPECTION: NEEDED PASSED BY -- s r 4 ' CONSTRUCTION INSPECTION: NEEDED ox f' 'af k.141j } It A5 . BUILT KLAN SATISFACTORY: (Y::ES pF r't 1 _ APPROVAL TO BACKFILL• DATE FINAL GRADING APPROVAL: DATE: FINAL CONSTRUCTION APPROVAL: BY___.___._______ ra '.5 "4. r' 'f l Of NORTI{1h 5046 O • : t Town of North Andover HEALTH DEPARTMENT �SS�cHu5�4 CHECK#: DD D E: LOCATION: H/O NAME: CONTRACT NAME: 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❑ Title 5 nspector $ itle 5 Report $ 5 ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 5046 M. rH 0�4. eo 1M0 O 9 Town of North Andover + '•,,,.o.: HEALTH DEPARTMENT �SS�cHuS�� 1 CHECK#: DATE: LOCATION: H/O NAME: CONTRACTOk"NAME: Type of Permit or License:(Check box) k ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ k e ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ F ❑ Swimming Pool $" r ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ r ❑ Well Construction $ 0 SEPTIC Systems: f; f' ❑ Septic-Soil Testing $ r ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ f 4_ ❑ Septic Disposal Works Installers(DWI) $ t ❑ Title 5 Inspector $ :tle 5 Report $ h y ❑ Other:(Indicate) $ r i r'. Health Agent Initials E White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form 6/t'e./Z> Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 every,page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection f jr-me mnXAothe.alters - any way. Please see completeness checklist at the end of the form. RECEIV Important: A. General Information JUN '10 2010 When filling out fomis.on.the computer,use 1. Inspector: TOWN OF NORTH ANDOVER only the tab key HEALTH DEPARTMENT to move your Benjamin C. Osgood, Jr. cursor-do not Name of Inspector use the,return. key. none Company Name 16 Hillside Avenue, Unit 3 Company Address Amesbury MA 01913 Cityrrown State Zip Code 508-328-4633 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 b the Local Approving Authorit ❑ Y PP 9 Y C 6/8/10 Inspecto Signature Date The system inspector shall s bmit 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. Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is North Andover MA 01845 6/3/10 required for every page. Cityfrown 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: ® 1 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 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 ' f I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 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 E] ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Ownee..s Name information is required for North Andover MA 01845 6/3/10 every page. City/Town 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. i ❑ ® 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. I ❑ ® 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 i 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 11 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 u< Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is North Andover MA 01845 6/3/10 required for 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 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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: no usage for 6 months or more Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: I Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 every page. Cityfrown 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: No record at Board of Health. Owner not available Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Built 1992 per Board of Health records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.0 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC Pipe OK in basement Septic Tank(locate on site plan): Depth below grade: 0.5 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: 2" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name. information is required for North Andover MA 01845 6/3/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Outlet tee missing 2" Scum thickness Distance from top of scum to top of outlet tee or baffle Outlet tee missing Distance from bottom of scum to bottom of outlet tee or baffle Outlet tee missing 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 missing. Recommend replacement of tee with 4"sch 40 PVC tee. 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 Oficial Inspection Form m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's.Name. information is required for North Andover MA 01845 6/3/10 every page. Cityrrown 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 da g Pe Y 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 �< 1507 SALEM STREET Property Address James Hartigan Owner Owner's.Name. information is required for North Andover MA 01845 6/3/10 every page. Citylrown 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. No evidence of soilids carryover or leakage in or out. Cover broken. Recommend replacement 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 e 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 4 chambers 48'x14'total footprint ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system T e/name of technology: 9Y: 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 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 every page. City/Town 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.): ' Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner information is Owner's Name _ required for North Andover MA 01845 6/3/10 every page. City mown 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 DIs-rAPit F'S t-'iA�IC 43.o' 2---TAN K RS'.O t— o OQ.% 6'is � 2 -o Xb-6 T604/ Pr t?J O Y 'S AcLI.gM 9 T • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is North Andover MA 01845 6/3/10 required for every page. City/Town 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: 5 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: 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 built in an area which was raised between 4 and 5 feet above adjacent area. USGS Soil maps indicate water is >6 feet below grade. _ 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 �< 1507 SALEM STREET Property Address James Hartigan Owner Owner's Name information is required for North Andover MA 01845 6/3/10 every page. Cityfrown 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 i. II INVERT ELEVATIONS 4" PIPE © FDTN. SEPTIC TANK IN _ SEPTIC TANK OUT _ 1 2,� PUMP TANK IN _ 2 FORCEMAIN t� of PUMP TANK OUT = 100.47 IST. BOX IN = 100.30 s -. DIST. BOX OUT = 99.97 3972 o END LEACH LINE 1 2 _ 99.9 END LEACH LINE 4L Lkf�e, REC ED 0 LgTF / DEC 1. 3 2005 Tq N F SLTr HE LTH DEPA ENT / 1 r A app x17 522.66' T.B.M. PK #3 TOP NAIL x7 IN PAVEMENT EL=96.03 F,yn, / X12 tD � X6 X13 LOT 24- A NT ^� X5 AREA=237,702 S.F. EROSION CONTROL X14 VEN =5.46 AC. 6 . / a pal xts / 798 / x18 a ��e ca B17• CO C X17 2�9 CC12 DR/ IV • / CC7 r4O t / CC14 CC13 'A CCB CCS :1 CC15 CC4 Tr � X18 /� � C4 � EXI C3 : RCP + INV.a91.89 1 C6 j 85 + I / EDGE OF_WF TLAN_' C2 1 4 —AS FLAGGED BY x20 cc1 WETLAND PRESERVATION INC. C7 2 �EX15T1NC RCP CC18 C8 022 _ 24'MV,91.97 c9 cC19 021 C70 X21 I 1 D20 ,� D16 D15 D1 D17 ! 3 X22 CI D78 \y f � CC2 r�j { C1 r D11 1 24 x233 ,a 1, f_ i� CC23 06 FULL CIRCLECV/ST cc25 CC24 c x 010 I RUCTION CORP 4 cta AS- BUILT OF DISPOScAL Yis S EM D7 SUBSURFACE LOCATED IN DOVER, ISA• D6 NORTH o� AS PREPARED F D °, DS �o ILFRIED ELSCH 0 1507 SALEM STREET NORTH ANDOVER, MA. 01845 iSCALE: 1"=50' 0 DATE: SEPTEMBER 11 , 2000 Ln i MERRIMACK ENGINEERING SERVICES PLANNERS PROFESSIONAL ENGINEERS • LAND SURVEYORS 1 ANDOVER, MASSACHUSETTS 01810 TEL. (978) 475-3555• FAX (978) 475-1448 W 66 PARK STREET1 I DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Tuesday, September 22, 2009 12:09 PM To: 'schruender@aol.com' Subject: I.R. -Septic- 1507 Salem Street Attachments: SKMBT_60009092211580.pdf; image001.gif Hi George, Here is the Septic As Built Plan for 1507 Salem Street. PaweQa V e&e& a& Pamela DelleChiaie Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20;Suite 2-36 North Andover,MA 01845 978.688.9540-Phone 978.688.8476-Fax pdellechiaie@townofnorthandover.com-E-mail http://www.townofnorthandover.com-Website Notes: If copied to BOH Members-Reference Copy Only-no response requested at this time From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Tuesday, September 22, 2009 12:59 PM To: DelleChiaie, Pamela Subject: Message from KMBT 600 1 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Tuesday, September 22, 2009 12:09 PM To: 'schruender@aol.com' Subject: FW: I. R. - 1507 Salem Street-Mortgage Plot Plan and pumping records Attachments: SKMBT_60009092211581.pdf; image001.gif Hi George, Here is some information from the file you requested. A second e-mail will come after this with the As Built. Pamela DelleChiaie Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20;Suite 2-36 North Andover,MA 01845 978.688.9540-Phone 978.688.8476-Fax pdellechiaie@townofnorthandover.com-E-mail http://www.townofnorthandover.com-Website Notes: If copied to BOH Members-Reference Copy Only-no response requested at this time From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Tuesday, September 22, 2009 12:59 PM To: DelleChiaie, Pamela Subject: I. R. - 1507 Salem Street- Mortgage Plot Plan and pumping records E 2 QUAN77TY P�V aAT-E OF P�[Rpq) -'i.'krUKb OF elD 0041 4 YA rJUN3. 0000 mNol mxq INS "AY'Y MAU KOOT3 L RACKPI tL 0 K LrN 6 SXCUSI'Yg SOLIDS IR, SOUDCAUY0 yek- P, P, SYS712m pumpj"N�) U I k kt)D SSS ...... 'z te,4Q,57" f�vv 5e - 4e � A149 DAT Ty Pl,!hjD6C-- '50 X 1"U-K� Otl RECFJVE r 0 FUNDI rt:its. RSAVY OMLASB AUG 12 200 KCKM A"Cf4-pleLD KU` &A'.A TOWN OF INORTH ANDOVEN ! 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X20 CC1 C2 6 85 C7 CC18 2 EXISTING C6 24'RCP INV-91.97 C9 022 CC19 X21 CIO 021 D20 D16 D1 13 D1 X22 D17 CC2 C1 } D16 24 X23{j( Cl } CC23 Di1 F�`C C/�CCe CO/F CCzs �4 16 c x �CT'ON, C D,0 CORP AS— BUILT c18 OF C20 C119 7c SUBSURFACE DISPOSAL YS EM LOCATED IN NORTH ANDOVER, MA. E D7 c� D6 AS PREPARED FOR o WILFRIED WELCH D o D4 DS 1507 SALEM STREET NORTH ANDOVER, MA. 01845 SCALE: 1 "=50' DATE: SEPTEMBER 11, 2000 MERRIMACK ENGINEERING SERVICES PROFESSIONAL ENGINEERS • LAND SURVEYORS PLANNERS 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 TEL. (978) 475-3555• FAX (978) 475-1448 - A M I , .. . , - .. 1.1111� .11 14 -._-.�.._.....�._, - . . . ,� - " .".- � . .�%- * "' ::�.�'' .� . . ..',..'. - - -." __ -.. - '' ""'. , . . :. .�� ;..... ,- ., ..... : � - ..... ,:.�:..*:: - .-. ..... * '�* -�-� " ..�...E:.- �..�**...'.'i-'�'���:,_-. , .�...- .';..''-.�'6*�ll�" �,. 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PK #3 TOP NAIL X12 !N PAVEMENT EL=96.03 / 0i (U.S.G.S.) X13 axs :BOSON CMIMX5 LOT 24-' A / 14 VEN h h AREA=237,702 S.F. Q , h =5.46 AC. 4 p\7 9 / X17 D V CC14 CC13 •"` CC7 X18 CCtS CCB CCS t9 y/ C04 C4 �c a �O oci a 24'RCA =DGE OF WETLAND ce C3 mv.-ot.a9 kS FLAGGED BY V TLAND PRESERVATION INC. 7C20 e5 C7 C2 Cti1a cs 24"RCP MV.-91.97 cQ 022 XV CC19 C10 021 020 Daof 3 �~� X22 Ot D17 CC2 C{ cl / Dt8 OC23 Dtt CIRCte CO/F ass CC24 a x NSU - C�ON, CORP D10 JILT cis c" c" JRFACE DISPOSAL YS EM IN D7 i ANDOVER, MA. a ;ED FOR a TFT) WRT SC H D3A- b4 D L—c—, O t �Tt1 A AoV ,h'cASS �JGAt��'• l" a 4.c' �ATE�: _4�27�Q2 4 f I - AC. � U u 4-4- r I t A s8v.yr � 1 ' r i l bl * E a� Tc A u a iTs T tTt�r� i u s v>"E iZ r►1 of THEA of FSETS USS oF' THEA PSutt✓D��aG=�uSPEGTo� �O 8 S1-tok.l►..i ��NlPt.ry DUc.,y Aw.�flrv- vLH vSE tS �oTZ� u '� w t-r N Tk f Z ou IUG fl rcT��.�t t�..�A-r,a u o zA �.t 6 . 0 3872 CoU t—o IF-," tTy o2.. AJ.o" (Cou F-o2,M tTY. � fCISTfREO� �1 H�aJ Gou s-t-2.�cr-r moo. �'fC LAW) W K E.►...t �t.J t VT. a-( z'7(aS • t SYS'T p L)A I k Ty ;7 � r. DATT OF P�J�jMN 1-Y RECQVED AUG 12 2005 K(Xm r,'' 9,:fN el TOWN OF NORTH ANDOVER HEALTH DEPARTMENT S Y SIT I P 7,p l; GRESS TF ;z- y L,3 ruRb (De Uts h A UN 3 IF t Y, INS KOOn "CUSIVE SOLIDS fL 00 D P, $OLrD CA KR Y()VBp X f, 10 ��- �•" t� cPw: N 23.1 FOM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP LjQg SUBDIVISION LOT(S) PERMANENT ADDRESS ASSIGNED BY D.P.W. ) 77 175 017 STREET 22AIAIK ERELT APPLICANT C " A/1l�(> �l PHONE .57og-- y6; 2 -7206 DA'Z'E OF APPLICATION J711 N C 7 129 j TOWN USE BELOW 1111S LINE PLANNING OARD -L� DATE APPROVED TOWN PLANNER-K DATE REJECTED CONSERVATION COMMISSION DATE APPROVED CONSERVATION ADMIN. TE REJECTED j BOARD OF HEALTH DATE APPROVED Z HEAL'11 SANITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS • � I � �'� DRIVEWAY PERMIT —S /WATER CONNECTION* (-Per/y' eti P I FIRE DEPT./s s „' f RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. .. s DATE �� 3 Sheet I of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED APPLICANT ASSESSOR'S MAP 1C�(aa4. ADDRESS PARCEL # LOT # STREETS ns` ENGINEER (,t ADDRESS 'tea PLAN DATE r2� R REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED �1 a 4�J`D i� 1 LOTG 2S 14 CIA J�V_,,uE, S i O E <Df- sy.5 L06"c-TI o --�� too c3y Tl &azD ov- Jj6a C,-t`� &<ekj i "CkZA C>p -ice 1-1 Ij T-k L sl -3r �rrz�r- o� ��ce -� u��� t�T o p c o J al� 1 t Fi n1e, lb A01 lop �pF.,&i LA 5 �' i So 9 Cg TIO IV%xi 0 111IDD . Trz ot �,�,� r�r d r ___ ____ _.G ._ ___--_.1'________ ___- _..._.__ .____._ __ ___�____�_._ Town of North Andover; Massachusetts : Form Na 2 f MORTq ` `.BOARD OF HEALTH: o » 4z19 a1 47 DESIGN APPROVAL FOR • �ss�cwus�� �: SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No Site Location rs�7 s�4.LC�{ 5 Reference Plans and Specs. ENGINEER. r �� • w .. DESIGN DATE Permission is granted for an individual soil absorption sew age'disposal system to be i d in accordance with regulations of Board of•Health r CFrAI AN BOARD OF HEALTH Fee Site System Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH • BOARD OF HEALTH ib q,v� 3� y� 16 OL 19 Y * APPLICATION FOR SITE TESTING/INSPECTION 7.9 AERATED SSACHUSE 1 V Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time J /� �r� Gtr r - CHAIRMAN,BOARD OF HEALTH Fee Test No. J f S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.