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Miscellaneous - 155 GRANVILLE LANE 4/30/2018
/ 155 GRANVILLE LANE 210/106.C-0060-0000.0 e / 1 rj ' i' e y q r Lot & Street G � Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: Approved by: Desi9 ner: W - Dul:-�6sl_)�51 Plan Date: Conditions: Water Supply: Town Well Permit: Driller: Well Tests: Chemical`" ate Approved Bacteria I Date roved Bacteria II Date Approv Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U° Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YE NO Well Construction Approval? YES NO Septic System Construction Approval? YES' NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: , APPROVED BY: • v Y � � r Y SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? �Y 0 Type of Construction: NEW . IR New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YEa NO Issuance of DWC permit: NO DWC Permit Paid? YES 0 DWC Permit# Installer: Begin Inspection: YES NO Excavation Inspection: Needed: Passed: By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: V-e-�/ Approval of Backfill: Date: Z `2 iz,2L By: 1 Final Grading Approval: Date: By: Final Construction Approval: Date: . _ By: Certificate of Compliance: Approval: Date: i �. NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �gSsgrED cHus�t�h Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION rael VVI 1e- Lao e Print PROPERTY OWNER M t ke 6:M i ns Print 100 Year Structure yes no MAP PARCEL:�&o ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ` kAddition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other x �- Septic n11Nell �fFloodplai'rr Wetlands rt Watershed Distnc Q'wOW Sewer. DESCRIPTION OF WORK TO BE PERFORMED: �5��4i � �-v�,✓�,� ��x � �t n�,( S4aJ f mow,, �� T. Identification- Please Type or Print Clearly OWNER: Name: Ki Lt Phone: ?91 Address: Lxo-e- Aa *: ' A&k Contractor Name: M1 P00I.S �,�i? YDS Phone: Email: Addres' . 40hc�ia �ncrt Cpt� 3 Supervisor's Construction License: 010-!:tb Exp. Date: 0-0- Is' Home Improvement License: 11 ' 2z4 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ����� '- FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund P►,Ons Submitted Plans Waived ❑ Certified Plot Plan X Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL . Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools `' Well ❑ bo Y,tic Vi ��e-r Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. Pennanent Dumpster on Site F1L�rto kb) THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS_ CONSERVATION Reviewed on ' ]DC-0 / Si nature , .1k COMMENTS \-j 0-� v >\/HEALTH Reviewed on `; Si nature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FE DEPARTMEIVTTempD T ,_L, _ umps erontsi F . �,, �: . IfLocated a"t=0x24 MainiStreet, Fire D"epat�mentsignafure/datery , _ _ ��.,,�-_ ,�1 Kv - pli ILDI ES 11"I P,Q'r5 sa � foT" ,� E' -f�l ZZ�. A � nOf f4Cc,K�iTEH , TT Is'71 b NvPwr- sex I+zs 151, emwlm •N � •o , i I.ar' 12 i i j7'r71T-rrrryrnrr rr r-,rr T-,771 ,4 i r �Elnf o 1n I p N I •s �t 2' 07/vE 1 I )-.I,EvJ LCA,54 i I m I I E►-D (11o7i5pl) i 1 I I cXj�� i ► I AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN t l�►�i I A"r,>O l X12 AS PREPARED FOR / ���,lHOFMgssgo �Ui- i AS �H dlrG ���� DANIEL yGN DATE: KORAVOS M I o Z�j�-pp o CIVIL SCALE: I "--4f a' No.37752 A09�cC/s O ^�SSIO�NA NGS MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 O TEL (617) 475-3353, 373-5721 i 150' f 0 M O O M / PROP POOL / 22 25' DECK EXIST HSE i i • 0 N ��. EXIST SEPTIC SYSTEM j i 1 150' GRANV/LLE LANE PROPOSED POOL �N Of MA sq LOCA TION PLAN 'P FOR Ri i 155 GRANV/LLE LANE N B95 IN '° F6IsTEe`������ NORTH ANDOVER, MASS. DA TE:MAY4,2015 SCALE 1"=20' r CHR/STIANSEN SERGI PROFESSIONAL LAND SURVEYORS ERS 160 SUMMER ST. HAVERHILL, MA 01850 TEL. 978-373-0310 02015 BY CHRISr1ANSEN&SERGI,INC. DRAWING NO. 15025005 3996 of,Non � _ n Town of North Andover HEALTH DEPARTMENT �SS�cNus°t CHECK#: `7/7 10 DATE: LOCATION: H/O NAME: CONTRACTOR 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) $ ; I't Tle Spector $ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 3996 Of NORTH,N. � A F: a9 xTown of North Andover `�'•,,,,,.. HEALTH DEPARTMENT ,SSMC HUStS CHECK#: zyX0 DATE: W AI UI LOCATION: H/O NAME: CONTRACTOR 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 _f $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ 1 ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 4fispector $ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer } Commonwealth of Massachusetts :RECEIVED ®� Title 5. Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Asfssme P 2 20Q9( V-oj 11 --e F—r Nor Property Address HEALTH DEPARTMENT —EYE L4 li(r rA Y- Owner Owner's Na e information is required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted,on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: _ only the tab key � �--� to move your ( /� �rS \�0Lk-)e- cursor-do not Name of nnspectot use the return �+ key. ley - � se tal'B(� l e Y o c Company Mme ,113 ?P,44eeJ Company Address 41 k�� UVV 6 ' " Cityrro n I If State Zip Code (925k---6 yo - q Telephone Number License Number B. Certification 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: R/Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Si ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not,evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for t ollowing statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the ptic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ss than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i i t • � Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 C; rtk Property Address Owner Owner's Name information is required for every page. City/Town 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: [3,1 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: W✓P- 1/9-cr42 or tt y p f l 7A4eij&p 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 t ollowing statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the ptic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ss than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ` M � S �� C j"_h�-rJ r �I 112 �tit✓ Property Address Owner Owner's Name information is required for every page. City/Town 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 distrib ' n 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): ;z ❑ The system required pumping more than 4 times a year due to br n or obstructed pipe(s). The system will pass inspection if(with approval of the Board of th): ❑ broken pipe(s)are replaced ❑ Y N ❑ ND (Explain below): Elobstruction 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 Boar Health in order to determine if the system is failing to protect public health, safety or th vironment. 1. System will pass unless Board of Health de mines in accordance with 310 CMR 15.303(1)(b)that the system is not functioni in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 5 eet ofa surface water ❑ Cesspool or privy Is w . In 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System.Form Noffor Voluntary Assessments /( L 11 1 Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, ' ny) determines that the system:is functioning in a manner that protects th ublic health, safety and environment: ❑ The system has a septic tank and soil absorption system S) and the SAS is within 100 feet of a surface water supply or tributary to a surface wate upply. ❑ The system has a septic tank and SAS and the SAS ' within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and th AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the S 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 alysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no er failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 24i Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/Disposal System Form-Not.for Voluntary Assessments LAj Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ E?( 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. ❑ L/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ LTJ' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 2 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must se a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each a following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet a surface drinking water supply ❑ ❑ the system is within.2. feet of a tributary to a surface drinking water supply ❑ ❑ the system is loc d in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) a mapped Zone 11 of a public water supply well If you have answered "yes"to an question in Section E the system is considered a significant threat, or answered "yes" in Section bove the large system has failed. The owner or operator of any large system considered a signi ant 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. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is 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 / L/ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Q, Were any of the system components pumped out in the previous two weeks? lam' ❑ 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? LJ ❑ Was the site inspected for signs of break out? 17 ❑ 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? �y ❑ 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: L�1 ❑ 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): --f —= Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): tsins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: S Does residence have a garbage grinder? El Yes & No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes [g""No Laundry system inspected? y1/9 ❑ Yes ❑ No Seasonal use? ❑ Yes 9"'No Water meter readings, if available (last 2 years usage (gpd)): Detail: cl� P0 Sump pump? Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.), Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ❑ Yes ❑ No f Non-sanitary waste discharge o the Title 5 system? ❑ Yes ❑ No Water meter readings, i vailable: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: C;,64-'n-e "' Date Other(describe below): General Information Pumping Records: Source of information: �C.v A)zf(� Was system pumped as part of the inspection? ❑ Yes QKNo If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Lvi 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i Property Address Owner Owner's Name information is required for every page. City/Town state Zip Code j Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 9-/No Building Sewer(locate on site plan): Depth below grade: 1-4-1 feet Material of construction: ❑ cast iron EJ'40 PVC ❑other(explain): Distance from private water supply well or suction line: �✓ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 0 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: /S�p (��✓ f?� X�/`,y Sludge depth: 15ins•09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not:for Voluntary Assessments i Property Address '- Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 � f Mow were dimensions determined? 41jr- ig77 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r e Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): I Dimensions: Scum thickness Distance from top of scum to top of ou t tee or baffle Distance from bottom of scum to ttom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r " �" GV It Ili G-•� . Property Address Owner Owner's Name information is required for every page. Cityfrown State Zi Code P 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 Y ❑ er(explain): Dimensions: Capacity: gallons Design Flow: gallo per day Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping. Date Comments(condition of alarm and. t switches; etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 or 17 I Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 1 Y S- <:;!r4hjvi`I6 Lri Property Address Owner Owner's Name information is required for every page. Cityfrown 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 Comments(note if box is level andAistribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.)- - ©y Ae f �-j er i yv�•yl/1'( co+c'ye;-r rr Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes El No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump-chamber, con dition pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate onsite plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required-for every page. City/Town State Zi Code P Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 2' leaching fieldsee, number, dimensions: ❑ overflow Cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): - ---� ��� c A � hid�•at. �.� 41 Cesspools (cesspool must be pumped as part of inspection ovate 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 groundwate nflow El Yes E] No i t5ins•09/08 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for 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 p ing, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydrauli ailure, level of ponding, condition of vegetation, etc.): t51ns-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (coat.) 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: E!rhand-sketch in the area below ❑ drawing attached separately moi" �- C9 3 43f�" mss' �d t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar t/ ❑ Shallow wells Estimated depth to high ground water: ` feet Please indicate all methods used to determine the high ground water elevation: L�1 Obtained from system design plans on record If checked, date of design plan reviewed: 6 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: You must describe how you established the high ground water elevation: i I Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist [Inspection Summary:A, B, C, D, or E checked [XInspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater EI/Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 bt —1 euwu I11U UGa 4U U11 1 1LULIL.111111L Sep 17 09 DE:45p DPW 8706888573 P- 1 S "NY RQCW Cwd mffvw m 8117&&x17,47 pmby Uft Evans Page 1 Town of North Andover Tax Map # 21 Q=t 06.G-0060-Oo00.0 Parcel Id 1706 ` 165 GRANVILLE LANE MCCARRAGHER, ERENAN 156 GRANVILLE LANE N.ANDOVER, MA Gin" c+» 101&inpie Farn ly MIR"Type 1 Reaxtentfat �izeTagd 1,83Aaes FY 2010 UD Mailing index Name/Address Thr Loar Number Activadow. Fmm Undl R.f MCCARRAGFERENAN 155 GRANVIU.E(ANE N.ANDOVER.MA 01845 913 Antt No CYde C cpeitl activallnaotive Oldg Id. 17361.0.155 GRAIMLLE 1.AI+IE Lack SU 9 Date 71=0093170011 03 Cyate 0:3 Active Account No.3170031 Service Gods Rata Charge multJptter/U®ers tAF MISCFFF ADON FEE am wa 7.82 t/ ri WRIER 01 ALL METER SIZE 72;76 UB Motor MaintsaWce Amount No.3170031 Serial No Status Locallon Btu 13242674 a Arative EEtT HHMETr*METE T Water $b 053 YTD eons Date Reading Code Calmumption Postod Dift 111 8/4009 509 a Actual 21 7C10f2t}Q9 VarlaAce 3/1212008 406 a Actual 10% 12/5MCM 488 a A.,fusl 22 4128/2009 .9% 9/812008445 a Actual21 1121114004 056 6/4P2M8 422 3Actual 23 1011{OW -11% 317/2008 SW a Actual 24 7/16fA8 174% 1717/200721 4111/2008 363 a Actualj 24 1122 OOB -10 4/412007lk % 611/4/2007 $34 ak4 of 19 10112/2007 10% 3113/2007 310 a Actual 24 7120/24D7 25% 121 MOG 290 a Acwi 20 4116/2007 4% 9/124008 211 a Actual 18 1111=7 AMA 6114/2006 248 a AcNal 23 I/2O&006 16% 3/712006 226 a Actual22 711QI20W 12/2111015 208 a Actual 12 4117/2088 -7% 9/14/am 183 a Actual 25 1/1712008 619/2005r3. 143 aA l 40 1a114=W 3/1812005 121 a Actual 22 7116TF005 12W2004 28 4/5t2008 51 T 11% 8110/2004 96 a Actual 20 1/1412008 75 a Actual 30 1Q/tt120(14 -24% 4/1211004 45 a Actual 11 713012004 34 a Actual 34 6/1712006' 096 C yr(er-- 09/17/2009 2:21PM [GMT-nufAnN Septic System Information 155 GRANVILLE LANE Printed On:Friday,July 21, 2006 System ID: BHS-2002-0848 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench • Design Flow: One Two Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Inspections: Inspected: Expires: Inspector: Status: 07/21/2006 Charles Roux Passes Comments: Title 5 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 Town of NorthC�dr Health Department Date: a� Location: � (Indicate Address,if Residentia,or Name of Business) Check#: js- Type of Permit or License:(Circle) ➢ Animal $ ➢ DumP ster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: 0 Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) Health Agent Initials 1679 White-Applicant Yellow-Health Pink-Treasurer C�'�MMONWEALTH OF MASSACHUSETTS i! E CUTNE OFFICE OF ENVIRONMENT AIRS ` P4RTMENT OF ENVIRO ENTAL;P ECTION (( s t1 d7-3 f TITLE;5 I, OFFICIAL INSP 'I I FORM-NOT F,OR �SS SSMENT$ 1 ' SUBS CE SEWAGE DISPOS YSTE ° PART A i CERTIFICATI §yl I, 4 '` xi`-. I �'&.4 a Y x , I r; t .•i Property Address: i YC� v1 V`' L�j `' y it i �1 CA. 1 .. e' all �p�W k •E k K ovt F -, I. V.li a I&wner's 1�Tame: " ' tt r «r.«fir r�lA 1"+Nr"'t�l+t 'rh nAT ° Owner's Address: 5 a m , f ru.F ,z�:t s - i ,' a• Date of Inspection: Vlf Name of Inspector: (Please punt) C�h wr I e s T R o we Ir'.I" p Company Name: Te"ik 1`r� I 1, `" Mailing Address: el L3 Ak+i�N 'Rd. � , I III I i T k Telephone Number: CERTIFICATION STATEMENT 1.( ;'; III �t �I I certify that I have personally'}respected the sewage disposal systemvat,this address IYd;that the information reported ,e 4 below is true,accurate and complete as of the time of the inspection ljli Linspection va 'pe'rformed based on my , ;. ft training and experience in the pr per function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pars ant,to Section 15.340 of Title 5(3 0 CMR 15.000) : e s stem: a I � ..� 1 �i i ' •� I' � � f Passes j Conditio Passe !�{i��, f k� i ! Needs Further patio by the Loc I 'Ap oving Authority Fails Inspector's Signature: ,Date.lt The system inspector shall submit a co of this inspection report to the Approving Authority oard of Health or a Y P PY F P PP g ,, h',� DEP)within 30 days of completing this inspection. If the system is a sha}'ed system o>�Ihas esign flow of 10,000 =r gpd or greater,the inspector and;the system owner shall submit the report to the approPri egional office of the DEP. The original should be sent to the system owner and copies sent to,the buyer,if pl' le,and the approving r i authority. j I, I; J Notes and Comments �j II �-, ..I ****This report only describe''s conditions at the time of inspection and under the conditions of use at that time. This inspection does nof�i ddress how the system will erform in the fu ' '• �" � h+ p y p tare under the same or different } conditions of use.. I ,tl 11�, Ilii � �N } •.li.�� ' 4 , , I f� Title 5 Inspection Form 6/15/,20 0 page I ;; r°''I�I 11 �.. �� �r51t t 111 r� "rPage 2 of 11 l f r OFFICIAL IN' ON FORM-NOT'F SESSMENTS SUBSU >SEWAGE DISPOSAL SY TE IN . ON FORM PART t € f CERTIFICATIOin �ed)l'll aye : • p�_.ty / 5. '' f 'tttt✓1G V l 11� l�j h:�e. Pro er Address: �. +I I, Owner:Date of Inspection.Ins ection Summary: I ALWAYS co a all p ar3': Ch CD or E/ r s• Ir� J ti 1 k9 X4{IA.'System Passes: z have not found any P I Which indicates that any o h ailure criteria' s { ed in 310'CMR 15.303 or in 310 CMR 15 304. y'failure criteria not eyalua d a;e incateY tY I�}�.,.,� ,. .,... .,., r�•y ,.I�a,.__ ... •� iP ftf''�l''� y _t .. V-pmmen /� �p �ML,�,n�/� {� Q 9 �/�,ie 3 I L♦ y�1 G'A Va U1�'l YI �l t�Y'iryl` Vjdf� �1r e�'I��II�G� �`j' � 44ncol 1 F � E h B. System Conditionally I asses:' 10 F ` One or more system comp on is as described in the"Condiassi'sectioanne I "be r ced or k r. repaired. The system,upon compleon of the replacement or repairs approved by',;thleI rd Health,will pass. <<< F f`t Answer yes,no or not determined(Y,N,ND)in the for the fol 9v ing statements.l Il o . etermined"please explain. ��;. The septic tank is metal•and over 20 years old*or the septic tan14(whether etal or not)is structurally ' l unsound,exhibits substantial infiltration or exfiltration or tank failure ls' nt. System will pass inspection if the existing tank is replaced with la complying septic tank as approvedpby�tlie B rd of Health. tr *A metal septic tank will pass msypection if it is structurally sound,notl1 g and if 'e irate of Compliance indicatingthat the tank is less; "' 20 ears old is available. n 11 1:r: ' i °r { J I Y �I I i'; i {ifs r !' � I ° r• ND explain: 4 � ! Observation of sewage) ackup.or break out or high sta 'c wa#e�:level}n the dr tib o}.box due to broken or ! h. obstructed pipe(s)or due to a broken,settled or uneven dis utiori bozo System will pas inspection if(with approval of Board of Health): Ja broken pipe(s)are r laced obstruction is re ved , distribution bo 1s leveled or replaced i,j { i !j i _ 4 ! ND explain: The system required pumpingmor than 4 times a year due to broken or obstructs pe(s). The system will s i } d n pass inspection if(with approval of tale card of Health):dl roken pipe(s)are replaced obstruction is removed ,, {+�L ' . ND explain: a 2 I Page 3 of 11 OFFICIAL IN ION FORM-NOT F� ! , �L ASSESSMENTS SUBSUR I EWAGE DISPOSAL YSTEM I P ON FORM ri t; PART, i 10 CERTIFICATIO cortin ed g 1 /s ► ndvjlle � t PropertyAddress: r ` { ' g �t ¢ Owner: WI Date of Inspection: '_� a, +. }.. V kC Further Evaluation is IleI N the Board of Healthy Conditions exist which',.� t k� further evaluation by the Bo He II th 11 d termine if the system 'is•failing to protect public hea I I or the environment 1 System will pass unless of Health determines in ac; r e with 3 0, 15 303(1)(b)'thatthe system is not funchoniii in a manner which will protect p cia1`(h;��ae dflie environment: Cesspool or privyis it-in 50 feet of a surface water 1; , Cesspool or privy)is ithin 50.feet of a bordering getal, etland or a, , it I# ' I IIT 2. System will fail unless the Board of Health(and Public Water Supplier,if teFmines that the system is functioning in manner that protects the public)ieal(h,safety d envi onment: The system has a sep i'c tank and soil absorption system(S ) the SAS"' within 100 feet of a — u I, I surface water supply o utary to a surface water supply t,.11 _The system has a sep tank and SAS and the SAS is wi a Zone I of a tpubli water supply. T , _The system has a ser 'ctank li and SAS and the SAS i 1 l 0 feet of a ter supply well. E The system has a septic tank and SAS and the is less 100 feet but,50 f t or more from a I private water supply we I Method used to dete e distan ;. + " . "This system passes if the well water analy ' ,performed at a D certified lab6ratory,for coliform bacteria and volatile org#c compounds dicates that the w,pllj is free from polht�tion from that facility and the presence of ammoriie 6i ogen and ate nitrogen is eq-t' j i oil,less than5,ppm;provided that no other failure criteria are triggered. A copy the analysis must be.;attached to this f..orm: kk •,,. P i f P 3. Other: 1 a tV 'JHI X i � t Page 4 of 11 d ` OFFICIAL IN JECTION FORM-NOT FOR VOLUNT` ASSESSMENTS SUBSURF E SEWAGE DISPOSAL Y EM!INSP ION FORM PART L ( CERTIFICATIO + co tinned) I Pro er Address: S 0+ ud V I Ile 1f Owner: 44 , It ` 'Date of Inspection: j :1 .1' 1 ° I t 1'• j,!—,D. System Failure Criteria pli able to all systems: ` -"Yo u must indicate" es"ori' ."to each of the followingfor all ections ►:. ,i.;Yes No � � l Backup of sewage' ty or system component d gyp`pve;loaoi ca a SAS or cesspool , 17 ischay -�`�7 l t [,, clogged SAS oroe sspoofµ�nt to surface o#;t}„el o �'rs wtu f��w die to an overloaded or F � l• ,�3 Static liquid level in the distribution box above outlet in eA due to an overloaded or clogged SAS or s,r cesspool Liquid depth in cesspool is less than 6"below invert or available vole, les 1/z day flow Required pumping more than 4 times in the last year NOT due.to clogged o tucted pipe(s). Number ' of times pumped1. +1 ,a� t Any portion of the'�SAS,cesspool or privy is below high ! �purid water el ft#�a t� i FI 3'��.• I I N r I r ✓ Any portion of cessp, of or privy is within 100 feet of a urface water sup ., o tributary to a surface , water supply.- � i"f �I� An portion of a cesspool or privyis within a Zone I ot : ublic well., ! t _ ✓ Any portion of a cesspool or privy is within 50 feet of a�rv�te water supply;well.;. Fx Any portion of a cesspool or privy is less than 100 feet blut!greater than 5 fe t rom a private water +,1 supply well with rio cceptable water quality analysis.[ 'his system passe if well water analysis, p F performed at a DEP certified laboratory,for coliform bacteria and volatil �o c compounds indicates that the wall is free from pollution from that facility and the;p gse of ammonia nitrogen and nitratenitrogen is equal to or less that 5 ppm,provided t n her failure criteria are triggered. A copy of the analysis must be attachedto this form.] 1 ( I�C Ij! .4 A )1 y t! I' I [ ! 3 N I V V (Yes/No)The system;fails. I have determined that one or more of the aboye f iiteria exists as described in 310 CM 15.303,therefore the system fails 1{The system owner h d contact the Board of Health to determll�le hat will be necessary to correct the failure. s ' — 4 1 ! r„II •�. E. Large Systems: I I i{�'it k To be considered a large system the system must serve a facility`.with a desig ow°of 10,000 gpd to 15,000 b f gpd• You must indicate either"yes”or'. o"to each of the following: (The following criteria apply to lar"a systems in addition to the criteria above it ;yes no the system is within 4Q0 feet of a surface drinking water upplit y the system is within 200 feet of a tributary to a surf a drmkuig water supply ({, {+ ;�, l,j 1 lid r }i � the system is locatedFi'i a nitrogen sensitive a a(Interim Wg�lhead Prote it Area-IWPA)or a mapped F . Zone II of a public water supply well !i I+, i 1( If you have answered"yes"to,any question in Se on E the system}f cpnl sidered a si �' 'c ithreat,or answered ' "yes"in Section D above the large system has f ed. The owner or operator of any 1 ' s considered a ' Ali significant threat under Section Efor failed der Section D shall upgrade the gysternl ce with 310 CMR 1 15.304. The system owner should.co tac a appropriate regional otfiee,of the Dep I I i fI1, f. I' 9J!jit Page 5 of 11 k <' tt t it i't' r � it i (` tjr1 r i " t�, OFFICIAL I ON FORM, NOT'FI3��VOL � SSESSMENTS t f. f : sltl SUBSU tSEWAGE DISPOSAL! Y TE IN ON FORM CHECKL .I Property Address: IOwner: li 'Date of Inspection: } �Ilf Idl 3ti �sCheck if the following have Ibe 'ne. You must indicate"yes"or"no"as o each` #t Mowing• ;,try sF '. 1• t � } IC ��� t �M1 1 ��I a: t 1Yes No �`y� •, Pumping informs Orovided by the owner,occu ant,or Bogard #Hl ✓ Were any of the system components pumped out in the'previous two we r Has the system received normal flows in the previous two week penod?; +� i , fl. , — ti ,gyp ;t ✓ Have large volumes f!water been introduced to the system recently or part f this inspection? r,a 1 ✓ — Were as built plars oll, e system obtained and examine (If they were,�}o v le note a N/A , g Was the facility or dwelling inspected for signs offsewaack up?t ;!, ; n Was the site inspect e for signs of break out?. ; l r4 11 f i4 ✓ — Were all system components,excluding the SAS,locate tion site. ij, 11 is i ,,.,�� ✓ _ Were the septic tank`manholes uncovered,opened,and ' intenor of thet 1 ;t t k' pected for the condition +(, of the baffles or tees,'«t aterial of construction,dimension§,depth'of hquic�,'�1 p f sludge and depth of scum?ir Was the facility own e (and occupants if different from owner)provided ,`fth' I I ation onahe proper maintenance of subs 4c sewage dis osal systems? <t.r 41r �, 1.°r r a Ir•� g sS P � I , r,l , The size and loca .a ofthe Soil Absorption System(SAS on the site has bg determined based on: �. �, . h� t{ Yes no d� !1:1,1:1 +Ju,��1,. Existing information.` or example,a plan at the Board of Health.' Determined in the field(if any of the failure criteria related.to Part C is at'iss �e approximation of distance t F �'%i is unacceptable) [310 CMR 15.302(3)(b)] '' it ,pa'�a' 4 r 4, �k. i A i 5 C Page 6 of 11 by .{ OFFICIAL INSPECTION FORM-NOT FOR„VOLUNTAR SESSMENTS '; SUBSURFACE SEWAGE DISPOSAL SYSTEM INS E ION FORM ' 4 PART Cj'1 '�� !� i� SYSTEM INFO TION1 i ' 7 tr Property Address: 5 I t rA✓lV1 n-t777 dl"Owner: '� . }r Date of Inspection: li ” a FLOW CONDITIONS .RESIDENTIAL Number of bedrooms(design)` ! Number of bedrooms(actuq DESIGN flow based on 310 F15 3(for example: gpd x#of be ooms) t� Number of current residents}, ' ' a I ,LSF 7 y Does residence have a garba� yes or no): D !g ��YY VV R KA q „yn,��s�Iaundrybn a separate;�ew �. es-oro): [ifeyes�s Laundry system inspected(yes or no)'AL4 'i Seasonal use: (yes or no):-�° • At Water meter readings,if available(last 2 years usage(gpd)): Q Q L�`e Sump Pump(Yes or no): 25'' Last date of occupancy:(iom�. ti► t COMMERCIAONDUSTRIAL , i Type of establishment: Design flow(based on 310 CMR 15.2p-3): gpd 1 Basis of design flow(seats/persons/ gft,et q Vii.i �I . Grease trap present(yes Or n0j.'I-: 1 � ' '� Industrial waste holding tank present! s or no): Non-sanitarywaste dischargedlto th . itle 5 system es or no). Y (Y Water meter readings,if available: Last date of occupancy/use: OTHER(describe): } I is ! ;! ig. i .•i GENERAL INFORMATION41 Pumping Records I�' I IES ;;I��'' Source of information: I / D a/ ( � � i,, Was system pumped as par o khe inspection(yes or no): j i' If yes,volume pumped:!i pons'--H w was quantity pumped,determined? - tl Reason for pumping: }} /✓ /a tit:; , TYPE OF SYSTEM Septic tank,distribution box"soil absorption system 1; of Single cesspool _Overflow cesspool ;} , Privy Shared system(yes or no)(#yes,attach previous inspection records,if an') F.i 46 _ Innovative/Alternative technolo Attach a copy of the current operatio and t ce contract(to be x, 1, � r e obtained from system owner)' '; ,t; Tight tank Attach'a'iZopy of the DEP approval .: _ Other(describe): Approximate age of all com oneants,date installed(if known)and source of information t, 43 V Were sewage odors detected when arriving at the site(yes or no) fl a T, I I�I i L Page 7 of 11 }}}{. '� '� ON FORM SNOT F I 70I;' SESSI IENTS OFFICIAL IN� 1 �.. � SUBSU '. }.A IEtNAGE DISPO$ALSYTEM,II1]S� ON FORM `PART �+; a �� _ ' • '` S,XSTEM INFORMATI, N�contuiue '1 i �k'yProperty Address: l �' Yl��� � 14V� �� A ir'iwr > r o ' �r"Owner: I `� # ate of Inspection: I; t 1 t BUILDING SEWER(locates 'Depth below rade: Material of construction: I` n�"'� 40 PVC they( ) r, i` t � � Distance from private waters ll ox suction line:•, t�TM?R +'(�� ! `Comments(on condition of 1�' 't g,evidence of leakage,etc)� 41� ;u�1 a `" 4. ,k Cl SEPTIC TANK: / t .:I R �! (locate site plan) Depth below grade: Material of construction: concrete_metal_fiberglass +I'F polyethylene�a other(explain) �l : If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no) ' (attach a copy of certificate) Dimensions: f 0 ��'i I' �-- /�$ d • ' i (i t � „ rs x 4 I, Sludge depth:' ! i' i a'hI a ,t sr t . Distance from top of sludge to b'o o sof outlet tee or baffle: r I�Pl '4 Scum thickness: Distance from top of scum to toptof outlet tee or baffle: Jk ' Distance from bottom of scum fto bott�o.;m of outlet tee or ba fle:' �f, �� ''` ' How were dimensions determined: Comments(on pumping recommendations,mlet and outlet tee or baffle condition,structural integrity,li uid levels 1.� ''�k t j as resat d to o et in ert,evidence of le k ge, tc.) N ', C a �.a -Q� �1 t tnr��I �!l I� h r! r i �IIii 14 GREASE TRAP: (locate on site plan) „ ppt Depth below grade: Material of construction:_co'crete_metal_fiber ass Polyethylene., ler ' �+ (explain): Dimension: i L i, ` r 1 Scum thickness: Distance from top of scum to top of outlet tee or baffl Distance from bottom of scum to' ottom of outlet t or baffle: il� ' 'r 1 Date of last.pumping: I, I t �� �t� t. Comments(on pumping recom�endations,ins and outlet tee or baffle condition,str c u tegrity,liquid levels as related to outlet invert,evidence oleakage tc.): I t 7 . Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION:(continued) f �5 �� o�t/1�� � r., �� ,Ik I` �� ►� Property Address: F . Owner: �. ' Date of Inspection: 7ro L TIGHT or HOLDING T t (Tank must be pumped at a{o t pection)} on site plan) 1# Depth below grade: ij r` Material of construction: o e metal fiber laseth lerie (explain) r —: . r� g -T p Yr y �y g r( P ) �c,,,...,.,. . unensions I1II I� II' I,1 Capacity: �' g lions Design Flow: I gallons/day Alarm present(yes or no): Alarm level: Alarm in working order( s or no): Date of last pumping: I 1 l } I Comments(condition of alarm and float sw' ches,etc.): DISTRIBUTION BOX present must be opened)(locate o site � lay Depth of liquid level above outle invest ~ i Comments(note if box is level a . dis ibution to outlets equal,any evi ence,of soh ds car over,any evidence of } t leakage-into or out of box,etc)I s �t/Q�' �� o V Q �Ue ,' cW { d r� PUMP CHAMBER: (loca oq site plan) Pumps in working order(yes. � Alarms in working order(yes or rio): Comments(note condition of pump c amber,c dition of pumps and appurtenances;etc. i € . 1' a 8 t x Wage 9 of 11 OFFICIAL IN r ON FORM-,NOT F0 OL ASSESSMENTS • � �' r. , �_, � ,r,r. r it .:. ,i �- , IT. SUBSUR EWAGE DISPOSAL . Y,STEM INSEE, ON FORM i PART r SYSTEM INFORM A'TO (contuiue fie 4 ji1 t 1 Poe Address: �'� Property r p �' gal#'Owner: i i I1 ryj r .Date of Inspection: Hj F;l SOIL ABSORPTION SY r( ): (locate on site p xc valet n Ired) If.SAS not located explain w f 1 � e F � � r S �� J,1 � �,• L.:1t�i 1 Im011�'�"i"71�1�1'�° Type I I .,! r ,t�I ,i� leaching pits,number: � leaching chambers,number I 1 i r � , f leaching galleries,number' s leaching trenches,number,.length: _ leaching fields,number,'dimensions: � overflow cesspool,number:_ I r innovative/alternative system iType/name of technology Comments(note condition of soil,signs of hydraulic failure,level of por}ding,dam �sc'il,condition of vegetation, t etc I 1 P CESSPOOLS: (cesspool!must be pumped as part of inspection) locate on site lar})F 11, Number and configuration: ' Depth-top of liquid to inlet invert: P � '� d ' Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes r no): Comments(note condition of soil,si s of hydraulic failure,level of pori ding,'conditiJn o getation,etc.): PRIVY:_(locate on site plan) 'd ! l a ,< q ''WU Materials of construction: Dimensions: Depth of solids: Comments(note condition of soi��signs of/draulic failure,level of ponding,condrt}on o e�etation,etc):�,. �6 I a g_ a �.j. � � y, •• 4 r d e E 9I r I'. I �,1, �' �• �hl�' r 1' c I Page 10 of 11 �1 F OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART SYSTEM INFORMATIO]�V (continued) J. .,".Property Address: /S '!-� r + �} Owner: Date of Inspection: I i. ' fir. `! ! ��' i * {, l r SKETCH OF SEWAGE DIS P SAL SYSTEM , , Provide a sketch of the sewage, posal system including ties,to at least two permanent reference landmarks or a benchmarks. Locate all wells wit 00 feet. Locate where public water supply enters building. , 4 Fst t � ,�r„�,.�", ♦,u' eef�qy,{tyy�.�'jt�T�t'"'�'iti"1�tM1y'e�d ''�i�� 1 J.• i � 7t � � i { d .4 �, �s i (p 7 + R r 1 r ' Ji°Page 11 of 11t " I 1 OFFICIAL INKS ONFORM-NOT FOR�70 .UN ((ASSESSMENTS , �; Al SUBSUR � EWAGE DISPOSAL SYSTEM INR ON FORM w. PART SYSTEM INFORMATION(continued) 3; , L . Property Address: s /9 t� /� •S'Yu� �. t �t Ips `,S .. 1 Owner: ' 'Date of Inspection: r S,ITE EXAM [ ' Slope T,! k f Surface water { , Check cellar Shallow wells Estimated depth to round wa ttfeet .a k� # '°� "� `°'N } P g.... 1tMr h I � ' Ir Please indicate(check)all methoL` us I d to determine the high groundwater elevaho11 rr -i•i s -1t e ��A I I —0 0 f ' Obtained from system deli' plans on record-If checked,date'of design plan revre g Observed site(abutting property%observation hole within 150 eet of SAS) I; tf.F` k Checked with local Board o Health=ex lain: �'' I 4 p Checked with local excava(' r's, tallers-(attach docurn'entatir C Accessed USGS da ase- lain: jj t e You must describe how you es lrsh'ck.the high ground water elevation: 1 JJ � s' s. V/ 0 kl..��k I ij I"a hilt III I. YY 4 if it it ri r:� �. ! IIF i 11 �r1 kK + 4 , � r 1 t FI k; 1'r I + •'( � R 3 wi � r � I r 1Vn1'1 [axulia. r ' • i �Uli UUl. ff .0 26 Livingston-St. 0 Lawell, MA.01.8�2 L 8? .2-7750 a (97$) 687-2-68 I Cirlistable Lawrence{.978) 849-9724 fl A C 4(r� h f T Date of Order Name Address Job LoCOWn TEpGRS YffM. ,rthMmaanl4Pbr+tn.ha�aatoMen++rro►004NOWarwnl'rrhtl+o�ooriwy'w�.er 1 r �y paMat xrs.at.1 axlW!.N a�M Rd pfORr1�b OW ur OnOrttN� of Olwl � p�rtce p,w,dui m0 .Yd er war-JQjcbp b rRvic+AtuO�d}1lL Per+ra^��, ''i bt}r%n _N of r porpr io r dolno vrFwn oek sd to di1VA't�lLW d'Cwb;. . i �rrek# PUMPING'SERY,t4" ' ;! T y . tI •"� �/_�� �!; � � i r _ _ •�'�'s� .t .frfr�[[i P 1 r ' Fla)d Roder--Mcdnilr a SinkilnrT l. 1 �Prr Aqua Jet SeMce Siand by Service uncover-lank Portable Toilet-Service sUMICEMM HCY7f6 -PAIL nMO{Mr TOfALMNEdW! ; _. JIF .;j f w;OR pROEWDBY i� Tom DATF tOMPIfT'a ,li dC�a lGd1�1�0�� ,�1� � "Th�rrk��ou; �rK . SIGNATURE Ohm.WW �OJetl4elh►w YMT�I11101t ;4 6 9'1 l __.Bear Pflus.-wwaseaaa-w► q I c f t 1. �1 Ii pI F d , 4 ii ; COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION RE ED y JUL 2 6 2004 TOWN ER HEALTH DEPARTMENT TITLE 5 OFFICIAL INSPECTION FORM—IOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM C1 ART C TION �'5 Property Address: / fin• a,�1b�v�.�e ; rnc� Owner's Name: M (?Arro a her" Owner's Address: 15r; .1420700 Date of Inspection: Name of Inspector: (please print) Orn Company Name: Mailing Address: Telephone Number: CERTIFICATION STATEMENT 1 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: a Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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 1 Lr- +. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 155 -> 6QAtdVr/lP 1,00- Owner:" (Lirroaher Date of Inspection: —( Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D r A. System Passes: , r 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: r B. System Conditionally Passes: 1114 One or more system components as described in the"Conditional Pass"section need to be replaced or J 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 determiried"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken piles)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 M' A Page 3 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �r� (� (lll�}'/ /�,►��� 1 1Ij20. N6. QNpQVe , rnC# Owner: 7 >-Q c 7e _ Date of Inspection: —Q 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 s 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 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance *"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ro Ail]VI /P, rf AI/) O MnVf. nen . Owner4 n.W r/I ahe r? Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No -- Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ,.Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool -Liquid depth in cesspool is less than 6"below invert or available volume is less than V2 day flow __L--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. _f-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 compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria 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:hf A .To be considered a large system the system must serve a facilitywith a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to4c6 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. 4 . Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: do LIJ Owner: ' ('-IT177i Date of Inspection: 2-`)'1 CL& Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yews,,.-No Pumping information was provided by the owner,occupant,or Board of Health J 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 b_affles 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: Yes-**'no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5-2 Y ELLn 1. Na •CIN�n►/er�,t��i . Owner: m(!�i rC4(7 b LA Date of Inspection: J I l 9-QU FL W CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR5.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): u Is laundry on a separate sewage system(yes or no): [if yes separate inspection required) Laundry system inspected(yes or no):_ Seasonal use:(yes or no):&U- Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: Q CC C)PI P d COMMERCIAL/INDUSTRIALn Type of establishment: t 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: V'V 5 Was system pumped as part of the inspection(yes or no): If yes,volume pumped:/5-0 Jgallons--How was quantity pumped determined? -7 gy cr 2 JSP%/-2 Reason for pumping: C l P r/e I�4 ri 5 7 2 0 r u, -r 1. TYPE OF SYSTEM -L-"'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): Approx ate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):1D 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 165 61'0AID01116 Owner:09('Y,n Yrs 1'1.eh r Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 4--"4-0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on conditionof joints,venting,evidence of leakage,etc.): r .1l3 5 , uv. <'ct itl7� T/ii' ,H SEPTIC TANKY(_S (locate on site plan) Depth below grade: Material of construction: v'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: /U X k r Sludge depth: 2 --1 , Distance from top of sludge to bottom of outlet tee or baffle: 3 2 Scum thickness: ' V " Distance from top of scum to top of outlet tee or baffle:& Distance from bottom of scum to bottom of outlet tee or baffle:/c� How were dimensions determined: o /-/ 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.): , v f 6W !u PP eJ AJ 4Plisr6 t/�Jr /V — Gig>C.ir L(-1.;7-1 ,6t I r--5 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.): 7 Page 8 of 11 4 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:L5� Y/ y/ 'yjl io Owner: �r _ ,� Date of Inspection: - - 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: /--�0d 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.): V/5 '721 i3v Tip _7&)1 /,, 6a0 rQJ//J/ Tiv /fid 4,5,41,cs e).2 C J ►-vim U u-r4" PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:'S /l Owner: ffl ,jrrn,.1-)e�� Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (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: Teaching fields,number,dimensions: U 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.): N� Si5 0 / Ig)(9R)gue-, c- G4i.�- /-.),g --e- 6 Z �_ a��i��G FTI1 Ti e xl' IVO 2 A44 d c 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 ponding,condition of vegetation,etc.): PRIVY: �(ocate 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 l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: I Sa qopido 1W O Q Owner: /) Date of Inspection: U -/%-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. L1, i4al� a j7° 413. 5 w��PV' 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 155 (I 1 Owner:' 12.L h o d Date of Inspection: U -7=1,21a24 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet r Please indicate(check)all methods used to determine the high ground water elevation: L, 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: r 11 Town of forth Andover °�S�LEO i°�ti Office of the Health Department '°° Community Development and Services Division William J.Scott,Division Director 27 Charles Street RSSAc►+usft North Andover,Massachusetts 01845 Sandra Starr Telephone(978)688-9540 Health Director Fax (978)688-9542 December 11,2000 Daniel Dumas PO Box 1264 Atkinson,NH 03811-1264 Re: 155 Granville Lane North Andover,MA Dear Mr.Dumas: I am in receipt of your letter of November 9,2000 concerning the repair of the septic system at 155 Granville Lane,your unhappiness with your installer,John Soucy,and his allegations concerning a"personal relationship"with another installer and the Town of North Andover. I have spoken with a number of other installers,engineers and staff about your complaint of possible bias on the part of the Town and the Health Department in particular. What I have heard from those I have spoken to, is that they do not and have not in the immediate past experienced any bias,either positive or negative,when working in North Andover. I can assure you that the Town,as far as the Health Department goes,has no relationship with anyone that would influence how any inspection is carried out. The Health Department has developed procedures, including checklists,for performing inspections. This has been done to allay any fears that "personal feelings"influence the carrying out of our duties. If I believed that this allegation were true and heard anything from objective sources that confirmed it,I would implement disciplinary action immediately. To the contrary,I have consistently found this particular employee to be highly ethical and reliable in carrying out public health duties in an objective manner. It is unfortunate,but true,that Mr. Soucy has not had a good year with us this year. There were some jobs,both before and after yours,which were not done in full compliance with the code. On at least one occasion the Board of Health fined him for a particular violation. The extra fill for your system resulted because certain conditions existed on your site that were not evident before the system area was entirely excavated. The leaching area had to be shifted somewhat because of the close proximity of the utility lines on each side of the leach area. The original plan was for the leach area to be 45'X 20'. The As-Built plan shows the area as 42' X 21.5'. On-site plan alterations occur fairly often because of the actual site conditions. The actions taken by the Health Department on your site to ensure compliance with the regulations,thereby resulting in the additional fill,were not unprecedented. I am sorry for your experience with this installer. Please rest assured,however,that the fill was necessary to complete the septic system repair appropriately. I wish you luck in your new home. Please feel free to call me with any questions you may have. Sincerely, f Sandra Starr,R.S.,C.H.O. Health Director Cc: W. Scott BOH File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONISERVATION 688-9530 NURSE 688-9543 PLA.NNIING 688-9535 Daniel P. Dumas PO Box 1264 Atkinson,NH 03811-1264 978 372-3289(8:30 am to 8:30 pm) November 9, 2000 Sandra Starr,R.S., C.H.O. Health Director Town of North Andover Community Development &Services 27 Charles Street North Andover, MA 01845 Re: Title V work at 155 Granville Lane,North Andover Dear Ms. Starr: We recently sent John Soucy a final payment for Title V work at 155 Granville Lane. I am writing to you to inform you of a situation that developed during this work.Although we were not happy with John Soucy's work(see attached copy of letter sent to Soucy with final payment),we want to address this one situation further with you. Mr. Soucy added$950 to the original job contract price. When we questioned this amount, Mr. Soucy informed us that the increase was due to a town inspector's insistence on adding more material than the approved plan called for and consequently more labor .costs. It was Mr. Soucy's statement to us that this additional material was not necessary and was the direct result of a personal relationship one of your inspectors has with another bidder for this job,ARCO Construction. Mr. Soucy was awarded our work because of his lower bid. If this is truly the case, then we feel that the Town of North Andover should reimburse us the $950 for unnecessary material and labor. We would appreciate your looking into this matter. Sincerely, Daniel P. Dumas Enclosure ±t Daniel P. Dumas PO Box 1264 Atkinson,NH 03811-1264 Mr. John Soucy Soucy's Sewer Service, Inc. 830 Livingston Street Tewksbury, MA 01876 RE: 155 Granville Lane,North Andover, MA Dear Mr. Soucy: I am enclosinga check for$6,115.00 as per our final bill for the completion of the P Y � replacement septic system at 155 Granville Lane,North Andover. For the record, I would like you to know that I am sending you this amount with reservations for the following reasons: 1. Your employee damaged my driveway and left it still covered with a layer of dirt when we were told it would be power washed. 2. This same employee caused damage to trees and shrubs that we considered unnecessary and reckless. Our contract with you included extra amounts for removal and replacement of certain shrubs. One such tree has already fallen due to a total lack of a root system, and we are sure the others will soon follow. 3. Broken branches that you personally told us would be removed from an expensive ornamental dogwood tree were left hanging. 4. You added$950 to the final bill and said only that you were forced to do additional work on the property because of a personal relationship another company, Tom Sawyer of ARCO,had with the town of North Andover. Your company was awarded our work because of a lower bid than ARCO, and we possibly would have chosen ARCO if we had known you would be adding extra dollars for exactly the same system design. At no time in the process did the design you bid on change. Based on the above, I cannot vouch for your credibility or workmanship to friends or neighbors who may be looking for a septic system contractor. Daniel P. Dumas Enclosure � 3 Address !���Q�-N V iG.�� �-�� _ Title of File . Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes. action Document/ document/ Num. Action Department Board of Appeals - Board of-Health -—Planning Board - Conservation Commission - Building Department I RECEIVED FO -A .��H ANDOV � FAUG 0 9 2004 OC SYSTEM i�MPINO RECO I= TOWN OFNORTH AN HEALTH DEPARTMENT N y M tN4("3WNEP,& A ZS YST E LO ATTON m-- G �k-rr• 2 ��'-- t t &A 7�o_ yhm septic I'm1h No y us HEAVY CkRF-kE BAFFLES IN PLAN.°t. ROOT'S _.. LF—A CfMFL€� L' Ac: . - EX(�F-,SSIVE So , FLOODED sLID i A -YOVE (-)T - R EX PL AIN '}aux► i�ttrzt day r- t— UM kit N I I i i i AS-BUILT CHECKLIST v LOT NUMBER, STREET NAME ASSESSORS MAP& PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM INCLUDING RAE nf.,5F4G'�� TIES TO LOT LINES &DWELLING, WELLS d. FROM SEPTIC TANK -6. FROM LEACH AREA LOCATIONS OF DEEP HOLES& PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS,DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS,ELECTRIC LINES, CABLE _ DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX = ✓� ORIGINAL STAMP &SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION&ELEVATIONS OF BENCHMARK USED lop r17� ��%x,2.9 i i .�_. ��f _,�_ J ,,,�"f � `,+� � r ,� ~� � �>. � � � facs � �r To: Vince Dube,Flansburgh Ai From: Susan Ford,Health Inspecti Re: Edgewood CC: Sandra Starr,Health Directo ❑ Urgent x For Review ❑ 1 Col TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 10/24/00 This is to certify that the individual subsurface disposal system constructed O or repaired (X) by John Soucy at 155 Granville Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The dersigned hereby certify that the Sewage Disposal System ( ) constructed; (V repaired: by L E-h1 die tJ.�1� located at I r5f Gjtcnflf was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# dated ' with an approved design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: q_z400 Engineer Representative Final inspection date: �I-ZG�-®o -jc-) J'— Engineer Representative AInstaller: Lic.#- Date: ZD— x3-00 Design Engi eer: Date. to*- T--*•dP i 23 North Andover Health Dept. 27 Charles Street North Andover,MA 01845 • 978-688-9540 Fax:978-688-9542 facsimile transmittal _ To: Daniel Dumas Fax: 687-2470 From: Sandra Starr Date: 10/03/00 Re: Septic system @ 155 Granville Pages: 1 CC: [Click here and type name] ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Mr. Dumas, This fax comes to verify that on September 28,2000 North Andover Board of Health personnel inspected the septic system at 155 Granville Lane and gave permission for it to be backfilled. There is only one inspection left,that of final grade. Sandra Starr, R.S.,C.H.O. Health Director 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . l . :.- . 4.. ►.. ;j - I f t , -A- 17 1� i , y I i I i 1 AJ . a INSPECTION CHECKLIST FOR SEP'T'IC SYSTEMS Yes NO Initia p� A. Bottom of Bed 1. Excavation to proper depth �fc. 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. �/ I Comments: 1 / Dyq /r�i.� e.,- aGt l B. Retaining Wall 1. Wall height width as specified 2. Waterproofed 3. Wall minimum 10'to I g facility 4. Wall meets specifications of p Comments: C. Building Sewer /+ 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact fine base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade? 9. Manholes at any 90°change 10. 10'minimum offset to water line Comments: �7© )4 (f 7/ uS SfrQl�� � /1 n D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade _ 5. Manholes over center and each tee �- 6. 3-20"manholes 7. Inlet tee minimum 12"under invert 8. Outlet tee minimum 14"under invert 9. Outlet line cemented 10. Air space 3"above tees 11. 2 3"drop from inlet to outlet s 13. Com ac_t_base with 6"of ''s rushed stoneunder tank P 14. Tank is watertight Comments: r Yes NO E. Pump Chamber 1. If separate from tank,compact base with 6"of 1/4"stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box 1. D-box level 2. Minimum 0.1T'(2")drop from inlet to outlet 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight T. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double-washed-'/4"- 1 ''/z" -pea stone Bucket test done? 2. Minimum 27of pea stone above distribution lines ri 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5.- Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not,then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan-Minimum 2';maximum-4'. 4. Vent present if<50 feet or specified 5. Distance between trenches minimum 4'and maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6"per 100' 8. Depth of trenches below outlet invert minimum of 6". 7 Yes NO 9. Pipes set on stable base. Comments: 1. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipe 6'maximum 4. Pipes connected at end 5. Separation between adjacent fields 10'minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: J. Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond C7- 7L SEPTIC PLAN SUBAUTTAL FORM LOCATION: ,%S� [_CY2Zyi,c1��J &A.) ' NEW PLANS: $125.00/Plan_ � 4 REVISED PLANS: YES $60.00/Plan SITE EVALUATION FORMS INCLUDED: (YE� NO DATE: 6�'0'-69-0 DESIGN ENGINEER: > DATE TO CONSULTANT: Lv 1 *If you want your plans expedited,please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. i Augg-09-00 09- 54 North Andlover Corn. Dev. 508 688 9542 P.02 .)un- 16-UO U9: 3:5A Paul U. IUrniae, vt/YLJ V/ts-At•0a-V31s Y.V3 June 16, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development ment and Services 30 School St. North Andover,MA 01845 RE: Title V review for 155 Granville Lane Dear Sandra, Enclosed find the"Checklist for North Andover Septic System Plans" for the above- mentioned site. The following is a list of all the`Problem'areas and deficiencies Port. Engineering has found. `r d Distribution lines of field must be connected by solid pipe(NA 15.01) v1 s a comment,the elevation at the point 15 feet from the field where the 3.1 slope starts q,,,�W is 80.5'. This may be higher than the elevation of the pavement of the existing ,�driveway that is within 15 of the end of the system and either the driveway will have to UQe made higher or an impervious barrier will have to be installed. (This probably would aoM be less than 0.5 feet,and may in fact not be a problem. It is not possible to determine this by the plan because the contours have an interval of two feet, and there are not spot elevations at the critical locations along the driveway.) If you have any questions or comments please feel free to contact me. Sincerely ; � �..- Carlton A Brown,PE/PLS Granville155.doc PORTIt I ENGINEERING Civil E:nginrrrH& Lood Survrvur, (Inc Harris Strert Newburypom ltd 0]95(1 0178)dfi5-R59t INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at re 'fative to the application of 70&Sv2 j s -mo dated L�z for plans by ney� ova and dated (- ;�--QC�) with revisions dated a— ' I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 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. b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from engineer must be submitted to BOH,after which installer calls for 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. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper 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. d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. 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. Undersign Licensed Septi Installer /Act, Date: /--C� Town of North Andover, Massachusetts Form No.a • \ NORTh BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT C14 Applicant CIL-- N/Ky E ADDRVS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. /a CH MA OARD OF HEALTH Fee D.W.C. No. %� : Town of North Andover, Massachusetts ^-- Form No.2 f NORTN BOARD OF HEALTH • OC °•b°- '=- °' DESIGN APPROVAL FOR AnD HUS SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant Test No. Site Location • Reference Plans and Specs. ENGINEER DEYGN U DATE— Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. I. Town Of North Andover Community Development & Services William J. Scott Director �o 27 Charles Street (978) 688-9531 # i # � �-•- North Andover, Massachusetts 01845 �9SSACHUS . Fax 978-688-9542 i 1 a Board of Appeals August 15, 2000 (978)688-9541 Building Bill Dufresne Department Merrimack Engineering (978)688-9545 66 Park Street Andover, MA 01810 Conservation Department (978)688-9530 Re: 155 Granville Lane Health Department Dear Bill: (978)688-9540 99� This is to inform you that the revised septic system plans dated 08/8/00 for the i Public Health site referenced above has been approved for repair. Nurse (978)688-9543 1 If you have any questions,please do not hesitate to call the Board of Health Office at 978-688-9540. Planning Department (978)688-9535 Sincerely, 3 Sandra Starr,R.S., C.H.O. { Health Director SS/smc 1 cc: Dumas 6 File v i 27 Charles Street North Andover,MA 01845 Telephone#(978)688-9540 North Andover Fax#(978)688-9542 Board of Fcix To: From: Fax: j�L �5^^ `f- Pages: Phone: Date: Re: CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: v Jun-16-00 09:33A Paul D. Turbide, PE/PLS 978-465-0313 P.03 June 16, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover,MA 01845 RE: Title V review for 155 Granville Lane Dear Sandra, I ! Enclosed find the"Checklist for North Andover Septic System Plans" for the above- mentioned site. The following is a list of all the `Problem' areas and deficiencies Port Engineering has found. o Distribution lines of field must be connected by solid pipe(NA 15.01) As a comment,the elevation at the point IS feet from the field where the 3:1 slope starts is 80.5'. This may m be higher than the elevation of the pavement of the existing driveway that is within 15' of the end of the system and either the driveway will have to be made higher or an impervious barrier will have to be installed. (This probably would be less than 0.5 feet,and may in fact not be a problem. It is not possible to determine this by the plan because the contours have an interval of two feet, and there are not spot elevations at the critical locations aloe . g the driveway.) If you have any quesyions or comments please feel free to contact me. � / 7 Sincerely Carlton A Brown,PE/PLS Granville 155.doc PORT ENGINEERING Civil Engineers R Land Surveyors One Harris Street Newburyport,MA 0]950 (978)465-8594 owe Location: Owner's Name: Map/Parcel:. �/ /0(' /WI' 6-0 Address• /�S C�/'t�cc ccs Installer. Tel-: (oNew 151501 Repair Date: Wetlands7l W Zone IIA49 Soil Symbol__LSoil IQame Soil Class Deep Observation Hole Logs Elevation Depth Soil Horizon Soil Texture Soil Color Soil hiottling % Gravel,Stones,etc � b y Iv t la C , 5c, Z.srsy r< � s �l- s h Parent Material Depth to Bedrock Standing Nater in the Hole' /74"Weeping from Pit Face-1r HGtiY: b`` t 1 yJL 1 Parent Material Depth to Bedrock Standine.Nater in the Hole: �Yeepin;from Pit Face FSHGtiY: Date !�"��� Percolation Tests Observation Hole r p-/ Depth of Perc Start Pre-soak I � Time at 12" Time at 9" I Time at 6" I Time(9"-6") I M I I Rate Min/Inch I ' Performed By: &&+, Witnessed By: �•p, i i Town of North Andover, Massachusetts Form No. 1 NORTH � BOARD OF HEALTH �•{/�)� /// p��t LED bq'•YQ V.I /! 'fin <o.... ,< APPLICATION FOR SITE TESTING/INSPECTION �9SSACHUSy Applicant NAME ADDRESS TELEPHONE r Site Location Engineer DDRES/S TELEPHONE Test/Inspection Date and Time l't 4.y31; Z� i CHAIRMAN,BO RD OF HEALTH Fee YJ Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 19 5 o w,. APPLICATION FOR SITE TESTING/INSPECTION 4 C HUs���h Applicant NAME ADDRESS TELEPHONE Site Location Engineer c.. tom' ��;__►_ �r NAME ADDRESS r�� TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. ' t BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: ~CO LOCATION OF SOIL TESTS: 155 &n�AOyi"a L.a►Jiv' Assessor's map & parcel number. 1jaj�zr' ,1 OWNER:—V--A1'1 TEL. NO.: ke ADDRESS: 1515r (wra /ll j�anl� ENGINEER: HCW4k* TEL. NO.: g75'5c:�15 CERTIFIED SOIL EVALUATOR: V►L- Qf-"j 5'r ( dad use Iand:,�esidential subdivision, single family home, commercial Repair testin ✓✓ Undeveloped lot testing N. A. C servation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 1276.00 per lot for aW construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75,00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1'-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testingsoil evaluation forms shall be submitted. V,AY I L 'T -776 30 we - } f w JU A s Oh t rIV --- - -- - ki c j s Zo { — r 1 � BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: —CO LOCATION OF SOIL TESTS: 155 Com. n-A�S vr"a Assessor's map & parcel number._ 1����z &V OWNER:- t2Aw 11�7 TEL. NO.: 04 *-015ay ADDRESS:--4� �afaoy_1`anle- ENGINEER: H6W--rklAt:Zi TEL. NO.:__ CERTIFIED SOIL EVALUATOR: _ �t� Q6gLsg (!N. A. 0 d use land:,residential subdivision, single family home, commercial testin �/ Undeveloped lot testing servation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of W6.00 per lot forenv construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75,00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1'-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. V ILL F L AA),5 - 5MO Cp .46� ` ITs u S ! N co,. a Se18�� we - - ,. Zo � � � APPLICATION FOR DISPOSAL WORKS CONSTRICTION PERMIT - � C u-RRE`�'T D, r STALLER'S LICEi SErr LJ DATE• �, �_ LOCATION:_I � L � l LICENSED INS �L : OL- c SIGNATURE: RTELEPHON T gyp( F,S� CHECK ONE: REP. : A NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUMT. Administrative Use Only 575.00 Fee Attached? Yes No Foundati As-Buiit? Yes No Floor ans? Yes_ No Approval Date: d2 �fl . P / 15-c attAig „;:/1444),-A r IF op J r i i - - •,�-•/,71 _ _ -- ,per � �f�`/ ` ID { I . 10,-j' s�> /;//7/!;�.y ol V'r 5V Xw Li PD ki 0 --- - . >l 4 I t -R f 1-4 If 1 �• _... - _. -- - . _ ;._..few r If r 1 ' TO: NORTH ANDOVER, MASS /V" 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at �a't �?fl/41Y V1////6 LONE North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 of Massy�yG� 10 -511 y rD L g. E eer� 6Zeg.f "Itarian Af'pRF�S� 'F�'� Y AWA r. Q TOWN ,OF NCRTH ANDOVER NORTH ANDOVER BOARD OF HEALTHyy., REPORT OF PERO TEST d d "J ADDRESS OF SYSTEM YA41-0��1-0�2�-�& /� DATE NAME OF PROFESSIONAL ENGINEER OR SANITARIAN CONDUCTING TESTS NAME OF LOT OWNER —ADDRESS �Pir-� SHOW APPROMATE LOCATION OF PITS ON SKETCH ON REAR OF THIS SHEET Total Soil Log: Topsoil Subsoil — Depths & TVees Water Level Pit Depth Time to Time to Perc- Tests Depth- Saturation Time Drop 1211 - 911 Drop 91i__ 611 Other Considerations: r 6�� ,� p�+,,Zen /lr,'�� Recommendations: f Signature 1 10 V :3 v� I?Ss /7 9 „ /0 : /A 3a 71V C24 71�r�4 J /vo ui J r TOWN OF NORTH ANDOVER NORTH ANDOVER. BOARD OF HEALTH REPORT OF PERC TEST ADURESS OF SYSTEM O� o/ DATE 7 ' 7 NAME OF PROFESSIONAL ENGINEER OR SANITARIAN CONDUCTING TESTS NAME OF LOT OWNER ��wc� ADDRESS SHOW APPROXIMATE LOCATION OF PITS ON SKETCH ON REAR OF THIS SHEET Total Soil Log: Topsoil Subsoil Depths & Types � Water Level Pit D til-; Time to Time to Perc Tests Depth Saturation Time Drop 12" - 9t' Drop 9" - 6" Other Considerations: Recommendations: -/ Gf,P-� / fC✓�.�' G?'�1.- C? i�,�/ It'4 z Z-Xe (2e)I le-1 a oe 1'2� Signature 1 �, }C rPL�1�1 s�/OGvi�VC J)o/7 f PROPOSED SaSS11RFA4E SEWA4E b1SPa--4e- cSl/STEM PROPOsEa Lor 6�e.4d/.vG v SPNt�. or' H -,-I>. DA?,//�, 6UM A 5 45 IVCYO �*dA �3 82 V T ..�. �30 woo C.4L / -� lkCSEP!/ eT BARBAUALL O R f / o SePTcc T14Z47' TAM K` WES7-;WARb C<RCGE pR�40' _ �r(r AE-5167AJ 4 A TA �-- -�— -- —� r EAP. Ae;�4 I ` - � (a ARAG E CELLgRe PLUMB/A 14 FAC/L/T/ES= A/DA/_E' Se-WAGE r oW EST/MATE : e,-00 \{1/ SEPTic rA/�/K /DOD G�J4 c ©� 8J %� .w� a t �Bso�ePrio�v AREA : 900 .SGS , FT' 8Z 0�' 0 , ¢ ZPERCO4,47-/oil/ TESTS \0 � lZ \ S,4T ro9" DROP lJ.2A T/DA/ /5 M/�! N!!N, it�ll�tl M/iv /Z" i /9 AVIV M/N. /irl/N. 1141". --_ ` i / 9•• ro (o" DROP / itij/N. MlN. A4/A.1. PEA?LOLA -/OA/ RATE I; Mnv.1/�v. �1i1i v�/v �1i�.�/N. �/Iil. !N. 74- l7 7"ESr P/Ts A/O 6;4eBA6E v/Sp0-s�lL DA rE A,M� 6e TOP EL.E!/AT/Oh/ 80,0 /A/ r17'6 10R OICOS6Z 24"rdsO.scve- SOIL TYPES An10 rim c= WATER rABcE r� LOCA r/o A/ e07 ro/1 ELEUA'rioRV TESTS COA/DUC TED BY J-Dz5EP,4! T. eQ2BAGAL C O TES7 5 W/rNESSED BY /UD. AAlbo t/E,C HEAL TI-I DEPT. `Vac PL.4AY D6.SI,,—,V C,2l T'E.t�/A cS'f-/EE'T I OF Ea�wacEw7-J CAPPED �itlD S C-> O 2=�" S' O" � � .5'-O"' � Z -�' � f� PE.2Fo�QATED P. II•C. P/PE �oe E4u/'vA�ENrJ PART/AL BED EA-1D cS�ECT/Otil � SCALE 12 �FO� SPEC/F/CA7-16AJS SEE <9ECTIOA1 .47- LOWE2 RA/ AIT-) D�gT21BU7-/01,/ BOX �DOO QAL. CONC2ETEE SEPT/C TANK ¢5 ¢"�eSOL/D �!/C., SEALED TD/NTS 45,5oepno1y .BES PGAAJ ea- A/D 7- TO c5SCALE 45" {� j P. SEALED I:S'EL.EG 7- 50e,/10 s0e/v - N �r0 -e e e o uPo /�., TO •3/$" Gf/..QSHE� .o - ee� e e _ o C.C�USNE� STONE a e ems' eo e�q,• 75.D ooco _ __ m o 0 0�=ap_ of •, � ab�o e e e V.C. P/PE Dle o e o 0 0 0 7� C�j G�USHE[7 STONE Q O �vovBGE N/AS/�ED t�_ Q 0 TO MEE7- A.A.S.Al.17 O. If + Iti 11 j H2O .4z35o/2P7-/o/y vE1� c�ECT/D/y ��20F/L E DoT 12 �� '�{�f �CALE �0�2. l�/=�O VE�C'T. ���- g Pi20F/GE 4A/L) PLA v Atilt/ SEC T/oNS SAASS'7' Z off' 2 _ � . . ��__ � / � o ,( � �l- YS� � � �- v � 3 M COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPAI&TWUM OF ENVIRONMENTAL PROTECTION ONE WRTM STREET,BOSTON MA 02108 (617)2924500 TRUDY CORE Semvtaxy ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPEC ION FORM PART A CEIR II WATiON Property Address: 155 Granville Lane,North Andover Name of Owner:Daniel Dumas Address of Owner: 155 Granville Lane,North Andover,MA.01845 Date of Inspection:5/612000 Name of Inspector:Neil J.Bateson 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority X Fails Inspector's Signature: Date:5/6/2000 The System Inspector sh s mit a copyis inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS .n �y4%0 revised 9/2/98 Page I of 11 Printed on Recycled Paper t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A y CERTIFICATION(continued) Property Address: 155 Granville Lane,North Andover Owner:Dumas Date of Inspection:5/6/2000 INSPECTION SUMMARY: Check A, B, C,or D. A.SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: B.SYSTEM CONDITIONALLY PASSES: One or move system components as described in the'Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or NO).Describe basis of determination in all instances.If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed III revised 912198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:155 Granville Lane,North Andover Owner.Dumas Date of Inspection:5/6/2000 C.FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance (approbmation not valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION(continued) Property Address:155 Granville Lane,North Andover Owner:Dumas Date of Inspection:516/2000 D.SYSTEM FAILS: You must indicate either"Yes"or"Nd'to each of the following: X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. _X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. _X_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E.LARGE SYSTEM FAILS- You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area @ IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B • CHECKLIST Property Address: 155 Granville Lane,North Andover Owner:Dumas Date of Inspection:5/612000 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No _X Pumping information was provided by the owner,occupant,or Board of Health. _X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _X As built plans have been obtained and examined.Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. _X The system does not receive non-sanitary or industrial waste flow.The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. _X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _X Existing information.For example,Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [I 5.302(3)(b)] The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 912198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:155 Granville Lane,North Andover Owner:Dumas Date of Inspection: 5/6/2000 FLOW CONDITIONS RESIDENTIAL: Design flow_150_ .g.p.d./bedroom. Number of bedrooms(design):-4_ Number of bedrooms(actual-4— Total actual4_Total DESIGN flow_600_ Number of current residents:_2_ Garbage grinder(yes or no):_No_ Laundry(separate system)(yes or no):_No If yes,separate inspection required Laundry system inspected(yes or no) Seasonal use(yes or no):_No_ Water meter readings.March 98 TO March 00=8900 ft3 x 7.5=66,750 gallons/730 Days=92 Gallons/Day Sump Pump(yes or no):_Yes_ Last date of occupancy:_Current COMM ERCIALIINDUSTRIAL: Type of establishment: Design flow: ged(Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:Pumped 1997,Owner System pumped as part of inspection:(yes or no)_No_ If yes,volume pumped:_,_gallons 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) VA Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information:24 Years old 12/13/1976,as built plan. Sewage odors detected when arriving at the site:(yes or no)- No-revised 9/2/98 Page 6 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION(continued) Property Address: 155 Granville Lane,North Andover Owner: Dumas Date of Inspection:5/6/2000 BUILDING SEWER:X (Locate on site plan) Depth below grade:24" Material of construction: X cast iron_X 40 PVC _ other(explain) Distance from private water supply well or suction line: Diameter:4" Comments:4"Cast iron thru wall.3"PVC in house. SEPTIC TANK:X (locate on site plan) Depth below grade: 12" Material of construction:_X concrete_metal_Fiberglass_Polyethylene_other(explain) If tank is metal,list age_Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions:7'x 5'x 4' x7.5=1000 gallons. Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:29" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:8" Distance from bottom of scum to bottom of outlet tee or baffle:13" How dimensions were determined:Subtract scum&sludge depths to baffle length. Comments:Inlet baffle ok.Outlet baffle ok.Depth of liquid at outlet invert.Camera pipe to d-box,pipe has dip in it.No evidence of septic tank leaking. GREASE TRAP: None (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: revised 9/2/98 Page 7 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 155 Granville Lane,North Andover Owner: Dumas Data of Inspection:516/2000 TIGHT OR HOLDING TANK:_None (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass Polyethylene_other(explain) Dimensions: Capacity:_ allons Design flow:_gallons/day Alarm present Alarm level: Alarm in working order:Yes_No Date of previous pumping: Comments: DISTRIBUTION BOX.:_X_ (locate on site plan) Depth of liquid level above outlet invert:2" Comments:D-box level&distribution equal.Evidence of solid carryover.No evidence of leakage.Camera all leach pipes,water above all inverts,sign of hydraulic failure of laech field. PUMP CHAMBER:—None,gravity system_ (locate on site plan) Pumps in working order.(Yes or No) Alarms in working order(Yes or No) Comments: Revised 912198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)) Property Address: 155 Granville Lane,North Andover Owner:Dumas Date of Inspection:5/6/2000 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: 1 Field 21'x 46' overflow cesspool,number: Aftemative system: Name of Technology: Comments:Soil,ok.Vegetation ok.No sign of ponding to surface.Signs of hydraulic failure,water above all inverts out of d-box CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: PRIVY:None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:155 Granville Lane,North Andover Owner:Dumas Date of Inspection:516/2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) House Garage A Water B Meter A to 1= 18' Driveway Ato2=19'6" Ato3=21' A to D-box=45' 1 2 3 B to 1 =28' Septic Tank Bto2=25'6" B to 3=23' B to D-box=52' Z.111 , 46' D-Box 21' revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION(continued) Property Address: 155 Granville Lane,North Andover Owner:Dumas Date of Inspection:5/6/2000 NRCS Report name Sal Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 4.5 Feet Please indicate all the methods used to determine High Groundwater Elevation: _X Obtained from Design Plans on record _X Observed Site(Abutting property,observation hole,basement sump etc.) —X—Determined from local conditions —X—Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) As per design plan,no water 4.5 below field. revised 912198 Page 11 of 11 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: 155 Granville Lane, North Andover Owner: Dumas Date of Inspection: 5/6/2000 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. Neil J. Bateson Bateson Enterprises, Inc. I.f \\F'hr,��rr{�I�f� " Y� iS�� y'trr�p`�1HSY `St�ir lLf�+i I 777 —-- 1 i�Stt,3{5 S�r � PY41� ✓• Irda7. lyl X111/ 1 , r S � � 44{Y \ f 1 J r�f f r `1 NSP♦' 'fir 4 r \rV 'A il�f� I\y I.�l� �r 1' 1\. S hJf 1- li !. I R,( f 4•., 1� ;,Lr•I IV rel .t� I I e r I OF N O.RT -1'A V sSTEM PUpr Co. Nc SYSTCMLO t`(�.ea►r t her � ce�z�m�le, ''cfr (•roni 11 i UANTITY f UMGD • I:r S �. r i/s I�I ullr. f`Y Ia \fu , � �� „ , (, I »1'UUI I,N0 YES. SEPTIC' TANK; NO \TUK/E OFSERYICE,' ROUTINE EMERCENCY <CUV,Q>C(�,NUITION _ '`h'ULL:T0 CUYCIZ. `FI('r`•YY,CI�1~rISC'' .', 13AULLS' IN I'I,ACI' L EACH IZUNUAC'K... 'CXGCSSIYC SOLJDS '� FLO:O.DEDI . `— � I ,504y1U, C`Ay;RIi,YOY R µr HCtR EXPLA.1N) -- f f /l t5�11frA.y��.4'�\'�I�l��j j`�.�T•{��r,l Itl f� , 1f�\\ r l.Y.�f✓'� &)ls 1"'.��`yj�j�rlf 1\�i' 1 �`tS I�� Jt tl fj� « .,y 1 r� t :.•I >isT.L PUMPC :'Q Y . . 1 �, � ( t 1 1 c�u.�-ir�l fNTSr 7777777 i, �+� `s rr l,ii '1114�jft,<��II clK� Y TitANS`rc SD !rv; y, .j...c.re F,.r:v;.lih:r•' .ryrj:(,1t if: r',. --------------- Commonwealth of Msachu `e .C.�]v M setts City/Town of NO(,Ph �dove S F Q 1 q 2008 System Pumping Record L Facility Information: System Location: �S CT ro n�v� Address City/Town State Zip Code System Owner: Name: Adress (if different from location of pump) City/Town State Zip Code � � - ' 38-g53q Telephone Number Pumping Record l Date of Pumping �j oq. �r(\V i Quantity Pumped U allons Type of System Septic Tank Grease Tra P______other (what) System Pumped by: Company: ROOTER-MAN 12 East Dracut Rd., Methuen, MA 01844 i Location where contents were disposed: i Signature of Hauler ,\ Date 6