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Miscellaneous - 151 STONECLEAVE ROAD 4/30/2018 (2)
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F 14 131 . 7( /3 1 , s3 4 O ? fa..T..-. v A = 3 • ?, 0 5a S117��a i 1 l 13 A a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 F yyti� V� I � TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECED Property Address:_151 Stonecleave Road_ _North Andover E� 2 2005 Owner's Name: Barbara Vogel_ 0 Owner's Address:_151 Stonecleave RoadANDOVER _North Andover,Ma 01845_ ToHEAOTH DEPARTMENT Date of Inspection:12/l/2005 Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810s Telephone Number: (978)4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ifs Inspector's Signature: hfA, , Date: _12/1/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After permit from B.O.H.,install new outlet tee with gas baffle&d-bog,inspection from B.O.H.,septic system now passes Title 5 Inspection. ****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. Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART c RECEIVED SYSTEM INFORMATION(continued) DEC 0 2 2005 Property Address:_151 Stonecleave Road- -North Andover_ TOWN OF NORTH ANDOVER Owner:_Vogel HEALTH DEPARTMENT Date of Inspection:_11/10/2005 SKETCH OF SEWAGE DEPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. of A to 1=51'6" D-Box A to 2=53' A to D-Box=54'2" B to Tank=11'2" Bto2=17' B to D-Box=20'10" 2 Septic Tank 1 Deck B A Driveway House To well a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F< , TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_151 Stonecleave Road_ —North Andover_ Owner's Name: Barbara Vogel_ Owner's Address:_151 Stonecleave Road_ _North Andover,Ma 01845_ Date of Inspection)1/10/2005_ Name of Inspector: Neil L Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority /ff F/ails Inspector's Signature: Date: _11/10/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_151 Stonecleave Road_ _North Andover— Owner:Yogeli_ Date of Inspection:_11/10/2005_ 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: X 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.Outlet tee in septic tank&d-bog needs replaced. N 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: N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: N 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 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_151 Stonecleave Road_ _North Andover — Owner: Vogel_ O Date of Inspection:_11/10/2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the 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 l of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance_ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free frompollution from that facility and theP resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_151 Stonecleave Road_ _North Andover_ Owner:YogeL Date of Inspection:_11/10/2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or`ho"to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'/z day flow. _No_ Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No Any portion of the SAS,cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a 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.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 YYoou must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_151 Stonecleave Road_ _North Andover_ Owner: Vogel_ Date of Inspection:_11/10/2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes_ _ Were as built plans of the system obtained and examined? Yes , Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes _ Existing information. _Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_151 Stonecleave Road- - North Andover– Owner: Vogel_ Date of Inspection:_11/10/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_600_ Number of current residents:_2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no): _ Seasonal use:(yes or no): No_ Water meter reading:_On well water_ Sump pump(yes or no): No Last date of occupancy:_Current COMA ERCIALMSDUSTRIAL Type of establishment:_ Design flow(based on 310 CMR 15.203):___gpd Basis of design flow(seats/persons/sgft,etc.):— Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available:_ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped three weeks ago,owner_ Was system pumped as part of the inspection(yes or no):–No_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: _ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: 26 years old,6/1/1979, as built plan_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Stonecleave Road_ _North Andover_ Owner: Vogel Date of Inspection:_11/10/2005 BUILDING SEWER_X_ (locate on site plan) Depth below grade:_28" Materials of construction: X cast iron X 40 PVC other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) 4"Cast iron thru wall.3"PVC in house, no leaks visible SEPTIC TANKS: X Depth below grade:_6"_ Material of construction: X concrete____metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: T x 5'x 4'_ Sludge depth: 0"_ Distance from top of sludge to bottom of outlet tee or baffle: 27"_ Scum thickness:_0" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle: 21"_ How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc._Inlet tee ok.Inlet baffle ok.Outlet baffle ok.Outlet tee badly corroded,needs replaced. Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Stonecleave Road- -North Andover— Owner:Yogel_ Date of Inspection:_11/10/2005_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOXES: X Depth of liquid level above outlet invert: --l"— Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.)_D-box cover broken,replaced it. Evidence of leakage.Liquid below outlets 1". Evidence of carryover,_ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm in working order(yes or no):_, Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 Stonecleave Road_ _North Andover_ Owner:YogeL Date of Inspection:_11/10/2005 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: _ leaching trenches,number,length: _X_ leaching field,number,dimensions:_1 field 20'x 451 _ overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil oL Vegetation oL No sign of ponding to surface_ CESSPOOLS: Number and configuration: Depth—top of liquid to inlet invert:_ Depth of sludge layer: Depth of scum layer: Dimensions of cesspool:_ Materials of construction:_ Indication of groundwater inflow(yes or no):— Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):_ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Stonecleave Road- - North Andover_ Owner: Vogel Date of Inspection: 11/10/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. A to 1=51'6" Ato2=53' A to D-Boz=5412" Bto1=11'2" Bto2=17' B to D-Boz=20110" D- Boz 2 Septic Tank 1 Deck B A,'--- Driveway House To well Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Stonecleave Road_ _North Andover— Owner:YogeL Date of Inspection:_11/102005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: _X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/30/1978_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 151 Stonecleave Road, North Andover Owner: Vogel Date of Inspection: 11/10/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system egon Bateson Enterprises, Inc. WELL DATABASE ADDREES: /k ACE OF ;N--_. iVY �N=Ir D_ prat^ � WE DEPT1H Or R t a; DRILLED b. DLI c u -OWN -=- - AT -itiSY�DA r--- . . � 1rfA�YCANE" Y -- : . — ffL rC'�II�aN Y _N d �CCfTAriCfiYA.��iS: Y TA, L- 6 � � �� ems/Ih- .� 7 ADDR�.�S• � '� AGS.OF WELL• � 0, �LL D= �:l 7vaL FEZ., T: WE'i.L LO.CATTON: � WELL PF;-` DAA: DEP i�=OF TYPE OF 'W::j .: a- DR.=ED 5. DUG C. L,LFKNiOWN TYPE OF WAS BEA:R_NG ROCK: -WATER A2iA YS_S DATE: I-ECI NLA.NGA. ,T- Y N IIG�=LIRON: Y N 07ri-tR CONTr�-A-NTE: Y N TM Commonwealth of Massachusetts Map-Block-Lot 104.6-0135- -- ------------- Board of Health Permit No North Andover 6HP-zoos------- -- ��► ,..:'.�. • P.I. FEE .�Nys F.I. $125.00 -------------------- Disposal Works Construction Permit Permission is hereby granted Todd-Bateson to(Repair)an Individual Sewage Disposal System. to 1%0 at No 151 STONECLEAVEROAD - ------------------------------ ----- I - as shown on the application for Disposal Works Construction Permit No. BHP-2005-072 Dated November 22,_2005 i i ---------------- ------------------------------------------ ----- Issued On:Nov-22-2005 Board of Health - - - - -.. ..u. .......... ...........c......iSUSaa.,el�n......... ....0 .`....... � ..nuv................nn..u.S�t�.., *" Commonwealth of Massachusetts Map-Block-Lot ��,••' �� 104.8-0135- Board of Health i • North Andover j f ., Certificate of Compli THIS IS TO CERTIFY,That the Individual a age Disposal System (Repair) I i by __Todd Bateson - ------------------- ----------- - ------------ - - i Installer at No 151 STONECLEA OAD -------------------------- - --------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2005-072 Dated November 22 2005 ----------- ---------------------------- ---------------- ------------------------------- Printed On:Nov-22-2005 Board of Health r%ORT egtio Application for Septic Disposal System TODAY'S DAT p:Construction Permit - TOVN OF °9 `� NORTH ANDOVER, MA 01845 SU $ 250.00—Full Repair °' �h .0 omponent �SACHSEt Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your air or replace an existing system component 77)--491,e cursor-do not use the return A. Facility Information key. rab Address or Lot# 1 5/ 5 To/-/Q- c-te4 v-9- City/Town Aid 1� 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump Gravity (choose one) ***If pump system,attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information . /IR,. 0 y L- Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Company fL�Address 7 City/Town State Zip Code Telephone Number(Cell Phone#if possible please) a. Designer Information Name Name of Company Address ------ --- ---- ------ ---- City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 N° TM Application for Septic Disposal System Of ,,cn F"qti� • �� �O.Construction Permit — TOWN OF TODAY'S DATE - " MA 01845 $ 250.00-Full Repair ORTH ANDOVER r �9SSACNt)`��{ ' $125.00 -Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: MIResidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and a of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issu y this Board of Health. Na Date Applica ' Approved:VBoard of Health Representative) ZNa Date pplication Disapproved for the following reasons: For Office Use Only: / 1. Fee Attached? Yes ✓ No 2. Project Manager Obligation Form Attached? Yes No 3. Pump S sy tem? If so,Attach copy of Electrical Permit Yes zilh No 4. Foundation As-Built?(new construction ronly): Yes_(� No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No -\ Application for Disposal System Construction Permit-Page 2 of 2 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at /J�/ `Sfi` �I R v� VV - relative to the application " ` �o�—oS for plans by and of I�°P-�Q �°�°''`�dated /�' — dated with revisions dated I understand the following obligations for management of this project: roved 1. As the installer I am obligated to obtain all spermits the approved glans Health and Phe permit s to s prior to performing any work on a site. I muthave when any work is being done. meowner, contractor, ro ect 2. As the installer I must call for any all inspections. company schedules an inspection and the manger,or any other person not associated system is not ready then item three shall be applicable. licable 3. As the installer I am required to have the necqssary rrequesting an completed prior inspection,ppwithout inspections as indicated below. I understand that requ completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a--$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. or b) Final inspection — giEngineer must t sbe submfirst itted totheir Boardinspection of Health, afters which installer calls for verbal OK from engineer inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. perform the work(other than simple excavation) 4. As the int only I.may installer I understand tha required to complete the installation of the system identified in the attached application for installation. I further understand that work by others ublicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction.steps: a) Determination that the proQer elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. b. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersi icensed Septic Installer � 91 ",� Date. I C! Disposal Works Construction Permit# TOWN OF NORTH ANDOVER °<No RT,1a { Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 400 OSGOOD STREET �, .,.i+' NORTH ANDOVER, MASSACHUSETTS 01845 �'SS"„�H„5 t� Susan Y. Sawyer;REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SEPTIC SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: LOT: INSTALLER: 5ry-N DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS �� ( - � IV, TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE 1. GRAVITY DISTRIBUTION...6� 2. PRESSURE DISTRIBUTION...❑ 3. PRESSURE DOSING...❑ 4. HOLDING TANK...❑ 5. ADVANCED TREATMENT...❑ 6. OTHER...❑ PUMP SYSTEM COMPONENT SUMMARY FROM PLAN 1. GALLON TANK= 2. LOADING OF SEPTIC TANK= 3. GALLON PUMP CHAMBER= 4. LOADING OF PUMP CHAMBER = 5. TYPE OF SAS = 6. DIMENSIONS AND DETAILS OF SAS: Comments: Page 1 of 4 TOWN OF NORTH ANDOVER °E NORTH 7 Office of COMMUNITY DEVELOPMENT AND SERVICES or•'to��� °°� HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SITE CONDITIONS 1. Existing septic tank properly abandoned...❑ 2. Internal plumbing all to one building sewer...❑ 3. Topography not appreciably altered...❑ SEPTIC TANK 1. Bottom of tank hole has 6 stone base...❑ 2. Weep hole plugged...❑ 3. Tank has been installed (H-20) Tank Size: 1,500 2-piece ...❑ -H-40 4. Water tightness of tank has been achieved (Visual)... ❑ 5. Inlet tee installed,under access port...❑ 6. Outlet tee (gas baffle or effluent filter) installed,under access port...❑ 7. Cover to within 6" of final grade installed over one access port,must be over outlet of tank if effluent filter is present- Inches of Tank...❑ 8. Hydraulic cement around inlet&outlet...❑ ****Comments: **** PUMP CHAMBER—n/a 1. Bottom of tank hole has 6" stone base...❑ 2. Weep hole plugged...❑ 3. Pump Chamber Installed_Combo tank Gallons; (H-20) (Monolithic) 4. Inlet tee installed,under access port...❑ 5. Pump(s) installed on stable base...❑ 6. Alarm Float Working...❑ 7. Pump On/Off Float Working...❑ 8. Total # of Floats... 9. Drain hole in pressure line...❑ 10. Cover to within 6" of final grade installed over one access port...❑ 11. Water tightness of tank has been achieved—Visual or Vacuum Test or Water held for 24 hours (circle) 12. Hydraulic cement around inlet&outlet...❑ Comments: Page 2 of 4 TOWN OF NORTH ANDOVER f NORTk 7 K Office of COMMUNITY DEVELOPMENT AND SERVICES 3?'b-t HEALTH DEPARTMENT p 400 OSGOOD STREET ► DA�T1D NORTH ANDOVER, MASSACHUSETTS 01845 'SS^CHUset Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX D-BOX 1. Installed on stable stone base... 2. Inlet tee (if pumped or >0.08'/foot)... ❑ 3. Hydraulic cement around inlet 8,,outlets... 4. Observed even distribution...C( 5. Speed levelers provided (not required)... - Comments: SOIL ABSORPTION SYSTEM 1. Bottom of SAS excavated down to C Soil Layer,as provided on plan...0 2. Size of SAS excavated as per plan...❑ 3. Title 5 sand installed,if specified on plan...❑ 4. 3/4-1 1/2" double washed stone installed...❑ 5. 1/8-1/2" (peastone) double washed stone installed 6. Laterals installed and ends connected to header (and vented if impervious material above) 7. Gravel-less disposal systems: type,number and location as per plan.........❑ 8. Elevations of laterals installed as on approved plan...❑ 9. 40 Mil HDPE barriers installed...❑ 10. Retaining wall (boulder / concrete / timber / block) ...❑ 11. Final cover as per plan ...❑ *****Comments: ***** CONTROL PANEL 1. Alarm&Pump are on separate circuits...❑ 2. Alarm sounds when float is tripped......❑ 3. Location of control panel: 4. Rated for exterior if placed outside...❑ Comments: Page 3 of 4 TOWN OF NORTH ANDOVER Ot NORTh 7 Office of COMMUNITY DEVELOPMENT AND SERVICES a 0 s P HEALTH DEPARTMENT 400 OSGOOD STREET * NORTH ANDOVER, MASSACHUSETTS 01845 ��SS„�NUg Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SYSTEM ELEVATIONS 1. Benchmark: 2. Rod at Benchmark: 3. Height of Instrument: INVERT ON DESIGN INVERT PLAN ELEVATION Building Sewer OUT 199.96 199.65 Septic Tank IN 199.75 199.24 Septic Tank OUT 199.50 198.98 Distribution Box IN 208.95 D-Box OUT Manifold 208.73 Lateral 1 HIGH 208.80 209.16 Lateral 1 Inv 208.71 208.69 Lateral 2 HIGH 207.20 207.54 Lateral 2 Inv 207.11 207.09 Lateral 3 HIGH 205.60 205.99 Lateral 3 Inv 205.51 205.53 Page 4 of 4 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record or% o 7 2013 Form 4. M TOWN OF NORTH ANDOVER HF 171 PA , n1y DEP has provided this form for use by local Boards of H tttt=( tier=f&rMAg,j ay esused, 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 1. System Location: Left/Right front of house, Leftrear of hou , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address •�� � ���`��� City/Town State Zip Code 2. System Owner. Name Address(if different from location) City/Town Stat � t �--Zip Code Telephone Number %— B. Pumping Record ? --3Mao 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No. " 5. Condi t4Pn Q�Systevm* 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lq�q contents were disposed: GLS. Lowell Waste Water Sign a Haule Date t5fom4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record �M yv v Form 4 DEC WL 1011 1i OIWN OF NOf�fiH ANDOVER DEP has provided this form for use by local Boards of Health. Other rrMAaW tM7 t information must be substantially the same as that provided here. Be s ng Is 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 1. System Location: Left/Right front of house, Left/qj i ht rear of hous Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address �! r � City/Town l State Zip Code 2. System Owner: \ �� Name Address(if different from location) City/Town StatGa, Zi Code a-mac 5� Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L . Lowell Waste Water SignAttJ6 I Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ,C-\ Commonwealth of Massachusetts RECEIV City/Town of System Pumping Record NOV 10 2009 Form 4 TOWN OF NORTH ANDOVER " HEALTH DEPARTMENT 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 tQ determine the form they use.The System Pumping Record must be submitted to the local Board of Health or- Or approving authority. A. Facility Information 1. System Location: Left Sof house, Right side of house, Left front of house, Right front of house, Left rear of ho fight r r o ou Left rear of building. Right rear of building. Address — Citylrown State Zip Code E 2. System Owner: Name Address(if different from location) City/Town State --ZipLode Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) D-S`eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: l 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location whe contents were disposed: L.S. Lowell Waste Water Signature of Hauler Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 IL u Commonwealth of Massachusetts City/Town of System Pumping Record OCT - 9 2008 Form 4 10% ANIr'C"ER r'T 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: Left front, left rear, left side of house. Right front, right rear, right sid of house. forms on the computer,use only the tab key Address to move your j IS cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Vo�� Name Address(if different from location) Cityrrown State i Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: El Cesspool(s) _ eptic Tank Tight Tank Cj Other describe : 4. Effluent Tee Filter present? 0 Yes EJ-Ivo If yes,was it cleaned? 0 Yes L] No 5. Condition of System- tat_)A2,t 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio here contents were disposed: .L.S.D Lowell Waste Water A - — igna ure of F Or Date t5form4.doc°06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of ��T 2 3 2007 System Pumping Record TOWN OF NORTH ANDOVER r' Form 4 HEALTH DEPARTMENT 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 ��-i to move your cursor-do not City/Town State Zip Code use the return key. 2 System Owner. �d Name Address(if different from location) CitylTown State( ,:�_7, -� Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 9-S'eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 8-14�0 If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: k �� V �� - 6. Systera FUM Name �J Vehicle license Number Company 7. Location recontents were osed: - Q _ AlIr Signatu,f(lpuldr Date t5form4.doc-06103 System Pumping Record•Page 1 of 1 TOWN OF � SYSTEM PUMPING RECO R G IVSD DATE: �. DEC 0 2 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) r��tA� ee� C f c cam. DATE OF PUMPING: QUANTITY PUMPED : c'—� GALLONS CESSPOOL: NO V YES SEPTIC 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: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste TOWN OF`NO&.TH ANDOVER 1 SYSTEM PUMPING RECORD DATE 140 V. O aoo 3 • - ` SYSTEM OWNER&ADDRESS SYSTEM LOCATION Vo Lc DATE OF PUMPING QUANTITY PUMPED fa CESSPOOL NO Y£S SEPTIC TANK NO YES4 NATURE OF SERVICE: ROUTINEEMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY COMMENTS: CONTENTS TRANSFERRED TO ;; t; CSF r,!()RTH A,•'D0`. _Z/ c^ ; 'q=ALTA TOWN OF NORTH ANDOVER :�'�� - 4 2-2 SYSTEM PUFYIPING R.E C 0 R_D I'Elv1 OWNER & ADDRESS SYSTEM LOCATION --- j J (example: lefc front of housr). it, 113 r4 c l( 0.1 I E OF PurnPINc:/®- (QUANTITY PUNIPUDW27T SI'OOL: NO L,/ YES SEPTIC TANK : NO YLS ✓� -�TURE OF SERVICE: ROUTINE 61 EMERGENCY »F(ZV:\T10NS: GOOD CONDITION NULL TO COVCIz _ HEAVY CREASE BAFFLL;S IN PLACE ROOTS LEACHFIELD RUNUACK. , CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O�HER (EXPLAIN.) I LM PUM PED BY J M FLATS: u � 11:'N 1'5 TIZANSFEIZIZED TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) ts- �. DATE OF PUMPING: 1 �S_ 1 QUANTITY PUMPED ava GALLONS CESSPOOL: NO YES SEPTIC 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: OO Ver SeDT & COMMENTS: CONTENTS TRANSFERRED TO: "Ara FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** i APPLICANT: /�/ Phone �YQ- 24L-Y LOCATION: Asses=sor' s Map Number Parcel Subdivision Lot(s) /S Street �� ��� T— St. Number Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Anoroved Con_ervat-on AdMinistrator Date Resected COT'S e.^.t5 Date Approved Town Planner Date Rejec=ed Comments Date Approved I Fcod Tnszector- ealth Date Re-;ec-ed /, � Date Approved Sep-:-c Insrec=r-HealDate Re;ec:ems Pu..�_C wcr::s - sewer,/water connect-ons - driveway permit Fire Depart-ent Received by Building Inspector Date � Board of Health, -North AndovergNass. SEPTIC 333TEK INSTALLATION CHMK LISP LOT # OVER DATE . HISILPFROVED, EXCAVATIOV ' OK- FAIL_ Reasonst � 3© FAn OK 1. Distance Toi a. Wetlands b. Drains c. Well 2. Water Line Location 3• No PVC Pipe fit. -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 b. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimensi s b. Ston epth C. Sp sh Pads d. T s e. ement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No garbage Disposal 9• Final grading 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 ipy Lo ruullu VVU1"1ikj ,r SUBSURFACE DISPOSAL SYSTEM CHECK LIST 1r-t/71, / NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON. M Title 5 Reg. 2.5 Fail OR The submitted plan must show as a minumum: Via) the lot to be served (area,dimensions,l,ot #,abutters) (Planning Board files) location and log of deep observation holes-distance to ties -v) location and results of percolation tests-distance to ties (-d)- design calculations & calculations showing required leaching area . —location and dimensions of system (including reserve area) -f}~ existing and proposed contours g)- location of any wet areas within 100' of the sewage disposal system or disclaimer (check wetlands mapping) • �� (-h)`"`-surface and subsurface drains within 100' of sewage disposal system of disclaimer (i)----location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) known sources of water supply within 200' of sewage disposal system or disclaimer (k�)--" location of any proposed well to serve the lot (100' from leaching facility) �Z� ) location of water lines on property (10' from leaching facilities) im)-'"`location of benchmark :::< driveways garbage disposers :p_ no PVC is to be used in construction COW 11q)�,- a profile of the system (elevations of basement, plumberss pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) -(*f�)maximum ground water elevation in area of sewage disposal. . system (3s)� plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks Reg. 6 (a) Capacities - 150% of flow, water table , tees, depth of tees, access, pumping, (b Cleanout �cd 10' from cellar wall or inground swimming pool 25' from subsurface drains North Andover Subsurface disposal system check list - Page' 2 Fail OK Distribution Boxes Reg.10.2 { Slope greater than 9.08 Reg.10.4 '�(b� Sump Leaching Pits Leaching pits are preferred where the installation is possible Reg.11 .2 (a) Calculations of leaching area (minimum 500 S.F.) Reg.11 .4 (bSpacing Re g.11 .1 (c Surface drainage 2% Reg.11 .11 d • Cgver material , Leaching Fields Reg.15.1 (a) %Greater than 20 minutes/inch Reg.15.1 (b)..---Area (minimum 900 S.F.) Reg.15.4 ,,(- I ) Construction of field Reg.15.8 (d) Surface drainage 2% Reg. 3.'7 (e 20' from- cellar wall or inground swimming pool Leaching Trenches Reg.14.1 (a Calculations of leaching area (min. 500 S.F.) Reg.14.3 (b Spacing (4 ft. min. 6 ft. with reserve between) Reg.14.4 (c Dimensions 14.5 Reg.14.6 (d Construction Reg.14.7 (e Stone Reg.14.10 (f) Surface drainage 2% Downhill Slope `_(.a) Slope y/x to be shown (b y/x X 150 = (to be shown Pumpp Reg. 9.1 .(a) Approval Reg. 9.6 (b Stand-by power SOIL PROFILE & PERCOLATION TEST DATA Town/CityNo.&Street Lot No. /02 Loc./Subdiv. ��e /eG Plan Owner Q,,r �J P Investigato��� ��,1� Observer_ ..�„� � O ' jSOIL PROFILES-DATE 1' E ev. �' Elev._ 3' Elev. 4'Elev. 0 377 __ ' O 3 77 0 -71 0 I � 2 2 2 lam ` 3 3 3 l k'Pf L —�+ 4 4 4 5 \ 5 5 5 6 l 6 6 6 7 7 7 8 8 8 8 � 7 e , 9 9 9 9 41 47 rA f 10 10 10 10 Benchmark- Loc.a-t-i-on Elevation Datum Percolation Tests-Date Pit Number 1 2 3 4 5 Start Saturation Soak-Mins. Start Test-Time :02 Drop of 3"-Time Drop of 6"-Time 3* 3o Mins. lst 3"Drop to Minse2nd 3"Drop l$ Notes &. Sketches on Back Frank C. Gelinas & Associates, North And. 3177 :l OZ/ is ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: zi 0 RA Ft ANL'0`�FR/ FD�f v(1F� F y�,:T11 Owner's Name:V=0\ Owner's Address: Date of Inspection: - (O' {$ NOV Name of Inspector: (please print) Company Nanw.:: P00 k_e Mailing Address• yY��,)I S,{ Telephone Number:—0-n-3-7a -27 1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4Date: —6),3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner:4ry` Date of Inssption: In 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: i B. System Conditionally Passes: �JJOne 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 es no or not determined Y N ND in the for the follow inn statements.If not determined lease Y ( , , ) a P 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 c indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water.level in the distribution box.due to broken.or obstructed pipe(s)or due to a broken,settled or uneven distribution box: System will pass inspection if(with approval of Board of Health): broken pipes)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: 2 Page 3 of I I t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � (}1"�r�/) �pC1 Owner: Date of Inspection: _ a 5-mi C. Further Evaluation is Required by the Board of Health: t 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'bnless 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: i _ 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 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. 4 _ 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 **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. ¢ 3. Other: 3 Page 4 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address 1 C G J Owner: Date of Inspe :ion: 1` 10770-� 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.tooverloaded or clogged SAS or cesspool �.' Discharge or ponding of effluent to the surface of the grdiihd or surface waters`due to an'overloaded or clogged SAS or cesspool il �[ 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''/z 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 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 coliform bacteria and volatile organic compozmds 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.] 140" (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. � E. Large Systems: " s •. .To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 4 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Ownerns-4m(2 Date of Inspecc on• Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes a Pumping inforpation was provided by t�e owner,occupant,tr 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? u/fiave 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 IN of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _,Z�— 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 locatio&of the Soil•Absorption,System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a pian 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)] G 5 Page 6 of l l • • R 1S 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:L�)� �( d V Owner: Date of InspC�,ti n•. I I- I •q FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -7 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1-12- Does Does residence have a garbage grinder(yes or n .)/�v Is laundry on a separate swage system(yes or o):-.- [ifyes'separate inspect onrir`equired]6 7 Laundry system inspected(yes or no): Seasonal use:(yes or no): x/() Water meter readings,if avai ble(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:—mss r 4p t w COMMERCIALANDUSTRIAL Type of establishment: /7 Design flow(based on 310 CMR 15.203): gpd 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: 1�r/- -,?,Q0— Was ou-+Was system pumped as part of the inspection(yes or no): If yes,volume pumped: vy gallons--How was quantity pumped determined? %Ic V cue. Me 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) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: q I Date of I 'ction:( — / ''L) BUILDING SEWER(locate on site plan) N . Depth below grade: :24 Materials of construction: -'cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: i;. Comments s(on condition of joints,venting,evidtnce'of leakage;etc:): ' A/v GP ��d s SEPTIC TANKV s(locate on site plan) Depth below grade: Material of construction: L--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: t S f Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: 3 to H Scum thickness: //L ' Distance from top of scum to top of outlet tee or baffle: 7"/G Distance from bottom of scum to bottom of outlet tee or baffle: �f How were dimensions determined: 0 K S/ Te Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �u�s•r P dy���/ i�Nr'�=� s �A— � I w GREASE TRAP: (locate on siteTlan) +l j r ,l 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.): 7 Page 8 of 11 F OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: {p( Owner:Vey-y,>\ _ Date of Inspe tion: TIGHT or HOLDING TANK://-(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions.`, ` Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:t f 5 (if present_must be opened)(locate on site plan) Depth of liquid level above outlet invert: 'zoo 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.): 1 1 PUMP CHAMBER:/ /#(locate on site plan) 4 Pumps in working order(yes or no): Alarms in working order(yes or too): Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.): 8 f Page 9 of 1 I ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (�� r Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site pian,excavation not required) If SAS not located explain why: Y Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: 1,-"Ieaching trenches,number,length: t a r 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.): 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of poinding,condition of vegetati6n,etc.): PRIVY: t(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.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM`INFORMATION(continued) Property Address: -,Lar Owner: O Date of Inspe ion:j /—/(D-( SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. �f ClL- 0 r f J•� 12 , �l 10 { a Page 1 I of 11 0 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM F PART C SYSTEM INFORMATION(continued) Property Address: RA Owner: NzCme` Date of Insp oo n: SITE EXAM Slope Surface water Check cellar s Shallow wells Estimated depth to ground Neter feet' ! l Please indicate(check)all methods used to determine the high ground water elevation: 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 how you established the high ground water elevation: !_ 1-7 tl q ,a C i +� 4 . II i $VNI i I YIN i-1ir�c d HSNNAOI ?!O 3 Q-3-A.Vd"3-a d - ,vbV i LC7-7 T �o Carl$ o � I � LUNE I � {r A se � •09 I tn :2 t3EDpooA4 I AV t- z • I �W j WELL 1 c ,={i 900 S.r`.' I-CACNW6 BCO 1 134 d. J E7D6 U r� 1 � I I ^5 - BUIL_T L-C):ZnTION 'MCNj�j�J?k t g " pi A16- I N F"Ro NT Q F L�T t3-, t i FkAKCOLATIOV 7e-sr rNJrActfO I . 71sT- P,T Z IVC .3 U,9,-ACE WA rCR - OF Sys r£M IEXfSriNG CONTOUI, J. Alp Sv,4,rACF Oio? 11ru6jIAPACe- L�44t►f 4� JuC3S cell-r�1�t �•.s�,s-+L ��sTc rl_ � ORAItis ot AfAIA/ CAYXf&Nrs Dw,7)4#&1 Loot F-r O+- sYs�M. W WAMR Ll NE 4 -FOP AND 5u8.3biL sNAc.c u - '• _ ':� Reyo6t o nT LEACH AAAA r±4Nd7 r•cR A V-j-qM�R aFP_ FT /,v Ac�f C `' S-M EC-IeAVE D'9ECT•ipV.5 ANP �e-A( ACED wrH .. F G«-���$ 5 .G �v wECCS aJiT'Nif� ,ao+1 � ;• �1'.� pare- Avcru5r :3 , f 978 DES IGEN DATA j CALCU LA-T I ONS ` SOIL OBSE RVAT IONS 15y, T 86R_i3A(T14"Q - WjTNE55 PERCOLAT ION -TEST NO. 1 v Z 3 4 - S -' — - - DAT E n//�n///,7i3 —' TOP-E LE VAT I ON BOTTOM- ELEVA`t ION SA-TURATWK -M%KS. �S --- 12" —+.9 DROP-MIPIS . - 9" DROP-MINS. - -- - -- -- PE f c . RAS E -M 111. 'P SO1-L PFZi3F1LE-DE£P PIT NO. I. -- 3 4 DATE_ 6/.3/77 -5/3o178 TOP-ELE VAT10N /30„2.5 /3/ 50 ,/3p.9 -- - 7D ra PARE NT SOIL y - X _ f WATER TABLE 3,-10, To ro ?,,0 • �� , CLAYEY Y T7LL VVATEP GRAVCL coMPAC r j Q N� WA CG ISA vCL WMEIZ col WATER TABLE_E LEVATI011 l+ •, �,g, Q �� �Q- BOTTOM ELEVATION 1 4Z - I 21.50 /2Q', 50 BUILDit4gT`I`PI` na+Eyl iAJCr B.R.,OR GAL. JUNIT _ GOO GPD FLOW 00 C-;PD FLOW x 15707 9 Qt GPD u.SE 006, r GALS EPT%C -TAtAK LE4GH ING� UREA f 1`D C;PD Flow x 1 , S F j G AL= 010 S F S F.D USE Ci0o S F P1T5 : ('20A 45) TYRE 4 .J vk- (Ty SIDEV4A,LL AR SF x GALs.� SF GPD BOTTOM A _ SP x GALS./ SF = GPD Tb-Tb LI=Ac+4+IAcx CApAc ITY _ _ _ _ _ _ _ GPD /'PIT © FLOW GPD/PIT= PIIS RE4D. USE,_.._... PATS 7keNCHES SIDEWALL ARE .� $F�LFx GALS Isr- = GAL./Ut4-FT. Bo-ToM SF/LF x GALS/SF = GAL./ LIN.FT, 1crrAL NCH LsAc1-IING- CAPACITY _ _ _ - - - GAL- bw T. J E,PD PLow -- G,nL4bx.PT.=_L.F.`TRENCNES REQ'D. USE LF Nur ES' P4\G E 2 o F S r V HV'M: ALL eLP-V&TloNb 2aVVIL To lbOTT'OM _ • ���c. `i'onK I*«aT �' OF& PlPft (INVE2.1) D ch wr a.. �5o,c I t*i-wr eft F-• -.��► oc ps aF. PIPS Gt ly. �s RAUE H ouS E l.�. �t rl Z ~�GKw MT. b 4 G D E —,4. PEQX-0a&TF-D (3tTVMINOV3 F • � Ft[iEIZ PIPE.. �GA�PEb C.*Ii>4) AlN. j=/YE o[/TLET pisx¢.. 4ox s v � MON- i�ERFOR.ATQ.p r�aa.;a2gTai> LEt►G.i��NG dtp • LIMIT LINE • PL s H OF- L EbC.-w t MG r->e- D No SCIAi.-E P:ukiTILL. 8 SSPM _TANK 14LET 4 .SHwT P26 -50 • z SaL. .. g. dW :_e-Z W • h �^ � � �o a 0 p p � ,�..a b IE 1 7 1 t� LLS tt'! ' l✓ ..PRO P(LtL s r •_. ." -!. ��1"R,�`�',�, -�►'�'1q,i" a`�-T., C t�; �. i 'd'�_ t rod, k��.►,y�. r t�►- �+ �7' W. �. Jr f' t....".r- � .�� '.�t y- liter �f��1 ► �,a,�`��' �� ��.�,i�[.t�f ,t�~ ! i�� �"1„}.{'...._j-r�. a «:-,.���-` ;� -_i.-•'r �f. �. S. '-.. �►' .+. • rte" a ►.Ci"rte ..J � r.',+ -� rr ! �_ `�, ,� ��t l� ? r . .�„' i i �' •-, J,., ` a s} _-t'f '�� ':r_ -��'JS' -.' 'a, . 40 dr �! r �� �� .moi� yam'. "%.'.�� _ j ,►.r�• .r-"l !-'�^ d: �..rfi � i�. r `11 41 ' • , ,r w V i. s ti " r +y \�tea►ql ► 1 '�► "�„'�1 ����7 \�+�"`►~`��'• ���0 �►� i • r: `�//� `/� � Y , ,/ f �� � � i I �� �� - �� I i - i ' 1 i 1 1 i rZc�I i r- i G 9 r I 1 t 1 t i y V 13 OR-rGAGE SURVEY LAN F RANK C. GzLINAS.REG157ER E O LAND SURVEYOR 451 ANOOVLCI STGI4ET - NORTH ANDOVER ., M ASS • Y 14EREBY CVRTtfY7HArTHEDvIipiNG SHOWN SATE S OPAYMIS PIANISLOCATao ONTH£ GROUND AS SHOwNANOTHATZTCONFORMS TOTHE ZONi NG PLAN REFERENCE . LAwSOFTHE CirY/TOWN OF . Bf 1NG LOT,_.] ON A PLAN BY _IL27/—No2v-ma ,/--M�- WMEN CONSTRUCTEO. DATED AND REC-OROEDIN 51GNE0: C OUNTY -" — — — — - REGIS-rRY OF DE40S . ;H Of414c� BOOK NO. PAGE NO. ,*. � r � O /f SCQTf C L /,5 N T NOTE PaOPERTYLtNC ANp gTRECTLINr, OFFSG.TS -_.4owNONTN%5, PIAN ARE- SPECiVlCAitY I:ORTHE Df7r6RMiNA-'+0N OF ZON+NG RE.QJtRT�MEwTg ONIN