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HomeMy WebLinkAboutMiscellaneous - 158 OLYMPIC LANE 4/30/2018 / 158 OLYMPIC LANE 210/106�0000.0 _ J U' L, r Commonwealth of Massachusetts Title 5 official Inspection F mill- AVER 0 Subsurface Sewage Disposal System Form-Not for Voluntary �9� NrsRpAR MENT M 1_00 y Pro rty Addr !l Owner Owner's ame information is r required for every page. ityRo 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 r 1'e V. u X cursor-do not Name of Inspector r use the return key. ^ I'I'e S (�y x , L VC] Company Name Company Address eae» City/Town State Zip Code �19_ �4o - S� q 1 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: [6 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ,ty Inspector's Signature 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•11/10 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 a Pro rty Add ss �V Owner Information is Wvner' Name I r� •--� required for —T� nll`� �� I v cf-• 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: 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: Aw ],� B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statyements. If"not determined, " please explain/th11an The septic tank is metal and rs old"or the ptic tank(whether metal or not) is structurally unsound, exhibitl infiltration exfiltration or tank failure is imminent. System will pass inspection if the exireplace ith a complying septic tank as approved by the Board of Health. A metal septic tank will pas ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that thss than 20 years old is available. ❑ Y ❑ N plain below): Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis osal System Form - Not for Voluntary Assessments Prop rty Addr s b �'l Owner gOner' NameInformation is required forevery page. ro n State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.); ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ N xplain below): ❑ The System required pumping re than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection ' with approval of the Board of Health): ❑ broken pipe(s re replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruc ' n 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 Boarof Health in order to determine if the system is failing to protect public health, safety;orthe ironment. 1. System will pass unless Board of Health deines in accordance with 310 CMR 15.303(1)(b) that the system is not functio ' g in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is w' In 50 feet of a surface water ❑ Cesspool or pr' is within 50 feet of a bordering vegetated wetland or a salt march Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 / Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i v m L ly � Property Addres Owner Information,is Ow ne ' ame I ���,I� required for (� every page. City/To n state Zip Co •lde Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 suppl ❑ The system has a septic tank and SAS and the SAS is within a Z e 1 of a public water supply. ❑ The system has a septic tank and SAS and the SZisw* n 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the than 100 feet but 50 feet or more from a private water supply well** Method used to determine distance: **This system passZealysis, performed at a DEP certified laboratory, for coliform bacteria indicates ae of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, proilure 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 ❑ Or Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ V Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ LJ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El Liquid Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow 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 o Property Addre �Y Owner k. Information is caner' NaJbAl--K ] -(' ✓�� g required for /VIPl J y p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q� Any portion of the SAS, Cesspool or privy is below high ground water elevation. ❑ Rr 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. ❑ Er Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ D/ 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.] ❑ This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ E� The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each he following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 et of a surface drinkiing water supply ❑ ❑ the system is wit ' 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syste ' located in a nitrogen sensitive area (Interim Wellhead Protection Area - A or a mapped Zone II of a public water supply well If you have answered " es"to any question in Section E the system is condidered a significant threat, or answered "yes" ' Section D above the large system has failed. The owner or operator of any large system consi ed a significant threat under Section E or failed under Section D shall upgrade the system in cordance with 310 CMR 15.304. The system owner should contact the appropriate regio office of the Department. Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a a / Prop rty Addres Owner caner' ame Information is required for every page. Ci y/Town State Zip Code Date of Inspection C Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑/ Pumping information was provided by the owner, occupant, or Board of Health ❑ L`� Were any of the system components pumped out in the previous two weeks? 6LI ❑ Has the system received normal flows in the previous two week period? ❑ 2 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) s� ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This size and location of the Soil Absorption System (SAS) on the site has been determined based on: B/ ❑ 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): Number of bedrooms (actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): zyd f 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 - � a �� >.•' Prop rty Addres y Owner � Information is caner' required for every page. ity/Town State Zip Code Date of Inspection D. System Information Description: 5') - D '3 v"/- — i( S Number of current residents: Does residence have a garbage grind r? /)o Pie LV_CLS,'__ 10/Yes ❑ No ��r—h t-" G r 1 yJ d r— Is laundry on a separate sewage stem? [if yes parate inspection required] ❑ Yes L� No Laundry system inspected? AIA El Yes El No Seasonal use? �" ❑ Yes El""No Water meter readings, if available (last 2 years usage (gpd)): Detail: 1 Sump pump? Yes ❑ No Last date of occupancy: C (.fJ y-r )+ 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 present? ❑ Yes ❑ No Non-sanitary waste discharged to e Title 5 system? ❑ Yes ❑ No Water meter readings, if availa e: Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 0 c Prop ty Addre s Owner ro O �7I Information is Owner' am n v �� �wn (�t�-required forC every page. City/ToZip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): /Z General Information Pumping Records: Source of information: Wass stem pumped as art of the inspection? ❑ Yes � No Y P p P p If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: LJ 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): 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 o /SR 0/VM/Q) J� Pro y Addres Owner ro �y Information is ner' am required for every page. ity/To n State DZipCte5 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 E3� No Building Sewer(locate on site plan): 2 Depth below grade: 3 feet Material of construction: ❑ cast iron 1J 40 PVC ❑ other(explain) AIB Distance from private water supply well or suction line: �l`A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: S feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: dA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: /Jr-�© �� C < Q s---V C Sludge depth /> Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposalSystemForm - Not for Voluntary Assessments Pro rty Addres Owner ro d f Information ican=16 s required for , y-P C every page. CltyIT wn / State Zip Code Date of Inspection u� D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle p2 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 , How were dimensions determined? SI od — Jyd 4 2. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): IAC f�O Y1. A/o/T) Ca7)-p c U O a2 �- 0 ) 1�c ,nv V LO VA Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fib glass ❑ polyethylene ❑ other(explain) Dimensions: Scum thicknes/g: Distance from ttee or baffle Distance from bf outlet tee or baffle Date of last pu Date Title 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 a OA ) < Prpjaarty Addre s 0lJ l� Owner �A( mer' Nam )� Information is f`��j�� required for q every page. ity/I own State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Dimensions: Capacity: AAlarm Design Flow: day Alarm present: ❑ No Alarm level: working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alar switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title 5 Oficial Inspection Form Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Prop ty AddrgAs Owner ro 6,0 1� Information is 0 ner' Nam ✓J vl .i required for o is every page. ylTo n 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 and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Oki. d t � l Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes 11 No Comments (note condition of pump chamber, of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavatio of required): If SAS not located, explain why: 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 LJJ Pro rty ddress Owner (4 d Information is Pner"' am required for dovoc 8 every page. Ci y/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: e leaching fields number, dimensions: OX gs— ❑ 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.): - d � (0�,6j 0� ca sl�sy\s 1� �IrA C4 U1 I C ,, - - c)�-e _ e � e 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 inflo ❑ Yes ❑ No Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s ti Pro ty Address/! Owner 6 _ ` Information is caner' ame r6/ ?45 required for �\ ��� � every page. Eity7fon State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of sZoydraulricure, level of ponding, condition of vegetation, etc.): I I 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 0 ► j Prop rty Addr s + Owner Y'O Information is caner' Name (� )Q j� b required for )-vq A6 6/ U �v�V ✓� �' every page. P /Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 2/hand-sketch in the area below ❑ drawing attached separately S �1 t 5 I-P G S � s Via . 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 01 M L Prop rty Addre94 M Owner , rdy Information is ne NamiY�l required for (VI a every page. City/Town b State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar ✓ ❑ Shallow wells Estimated depth to high ground water: —� L feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: _/ Date LJ 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: G� V'--L � ± 3 ct Before filling this Inspection Report, please see Report Completeness Checklist on next page. 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 Lij. a Pro rty Address Owner ,6 a� Information is wne 's Name 9(' o I g � 1 ) JIlk / required for — Iu every page. P ity/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information - Estimated depth to high groundwater L� Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 Town of North Andover Of� ean ra'1ti Community Development and Services Division p= °°� Office of the Health Department 400 OSGOOD STREET °i N'ortli Andover,Massachusetts 01815 �Rss�cwus��a Susan Y, Savvver,RENS/CSS Public 11.ealth Director (978) 688-9540-Phone (973) 688-9542-Fax Date: Address:f550 �tL ,North Andover,MA 01845 Re: Application for: d i� AO&/ Dear: Your application for� GSL y'GliY1 at /5Y e)'/;/V/2_has been reviewed by the Health Department. The application was denied on, 2004 for the following reasons: 1. e,/ Missing information 2. ❑ Passing Title 5 inspection of septic system required p®-5-se 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the problem(s): If#1 isctyecJked, please supply: Floor plan of existing and proposed addition-all rooms b'j Certified plot plan showing house,septic system and proposed project in scale If#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If#3 is checked: a. Relocate the project If#4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Reviewer Cc: Building Department File LS(),Ah.0 411 .11'!'I ,AI .`;oX =)`ll si'il.!)I ,i i R`:. l()`•:bfiA_l;i il) Ail'I2 �1{ V,-1) 0 111_1VVIN(.i 3-. NORTH i Of 4t�eo .e7.yO; A TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION °•AT91 ��Ss�cH�SE Date Received: Permit NO: Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION l Print PROPERTY OWNER (dF"� ���—�%print MAP NO.: /06 -9 PARCEL: )25- ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑New Building �G' One family ,_-crAddition ❑Two or more family ❑ Industrial 0 Alteration No. of units: .P-Repair, replacement 0 Assessory Bldg ❑Commercial -P-Demolition ❑ Others: ❑ Moving(relocation) ❑Other ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED l, __ _ _ G�WI- 1 t -- _ Ws w 1 cam. L,0 j '"/�� t��. J• S pi's C J "ZL,G C o[4tA Identification Please Type or Print Clearer q Phone: OWNER: Name: Signature �-- i Address: e `y��-C r_;�l i.2�"�i�l>Bone: G.�3' CONTRACTOR Name: CL-)Aj C Z r� � Address: 5 �� � es-k "� Supervisor's Construction License: Exp. Date: Home Improvement License: j 2- Exp. Date: ARCHITECT/ENGINEER � i N I 1 CZIL) Name: Phone: AG _ Address: 41'4 -Sr Reg.No. Al a,v chi lwg 1lw, Nw v:3 i v l FEE SCHEDULE:BULDING PERMIT.$10.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON $1zs.00PER S.F. rr� / 4: 0C) x10.00-FEE:$ Total Project Cost :$ cam. . '�' Receipt No.: Check No.: Building Setback ( Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: '2— Total square feet of floor area, based on Exterior dimensions.1. Total land area, sq. ft.: `/ 3� S-66 NOTES and DATA—(Por department use) i ' I Doc:INSPEC TONAL SERVICES DEPARTMENT a3PFORM05 TYPE OF SEWARGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer ❑ Well 17Tobacco Sales ❑ Food Packaging/Sales 11 -40 Permanent Dumpster on Site El (septic tank, etc. NOTE: Persons contracting with unregistered contractors Flo not have access to the guaranty f Signature of Agent/Owner • Signature of Contractor r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED WOPLANNING & DEVELOPMENT ❑ ❑ []Water Shed Special Pen-nit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED j3 CONSERVATION ❑ ❑ I COMMENTS �,- DATE REJECTED DATE APPROVED HEALTH , J COMMENTS' t � . Zoning Board of Appeals: Variance, Petition No: V Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection signature&date Temp Dumpster on site yesv__no_ Fire Department signature/date Building Permit Approved and Issued by: 1 ���� •yam t 'T s tf , G20 Sal- f. ( �.t � 1 e •�E....1 t I -7163 1. i t E , M1_ ' � I . 4 .. c- .l ..� .� w � 3 �� `- �`�y � �� r �i -:. :. ' , . � .... z ... �_ t: f `s ' � �� � ' ._;. s / � y � , � � � s � � �'��� � I� ... .. _� ..: . ' ` � 7 .,, --i • ` � J j 1. ._ ,- � o 7F-/ 16 1 ") ' - Y j�� 1 ,*`\�{� Its`___._.,--•. -�...:1 r,'._ v , f s r r t .. i 4 s e a 4 � a A7` y = i iT ' s t F ;a p d � 'e a . \ COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � _ r DEPARTMENT OF ENVIRONMENTAL PROTECTION i v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: � Owner's Name: fiW� VE, / Owner's Address NOV Date of Inspection: /Q 8•—O/ 5M Name of Inspector: (please print) eh A rle S X R o WC r Company Name:'Tewts 6y-Y4 -celo.•r CeYy;ce— r Mailing Address: a e P4*eZ Rd. k Telephone Number: 7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 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 i ****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 orm 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /.7—Q Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: __Zhave 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: �-S�� 1eel M0414,4e, B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be r aced or repaired.The system, upon completion of the replacement or repair,as approved by the Board o ealth, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statemen . f"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank ether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure i minent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved the Board of Health. *A metal septic tank will pass inspection if it is structurally soun ,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 high static water level in the distribution box due to broken or obstructedpipe(s)or due to a broken sett led or ven distribution box. System will pass inspection if(with approval of Board of Health): broken ipe(s)are replaced obs ction is removed di ibution box is leveled or replaced ND explain: The system required p ping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with appr val of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. Further Evaluation is Required by t/rotect of Health: Conditions exist which require furthtion by the Board Health in order to determine if the system is failing to protect public health,safety or nment. 1. System will pass unless Board of termine accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manh will rotect public health,safety and the environment: _ Cesspool or privy is within 50 face waterCesspool or privy is within 50 ordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) ermines that the system is functioning in a manner that protects the public health,safety and env' nment: The system has a septic tank and soil absorption system(SAS)and th AS is within 100 feet of a surface water supply pp y or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is thin 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 dete a distance "This system passes if the well water analys' ,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds in cates that the well is free from pollution from that facility and the presence of ammonia nitrogen and n' to nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy o he analysis must be attached to this form. 3. Other: 3 Page.4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /S T Owner: 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 clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or s ce waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet inve due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below inve r available volume is less than 'h day flow Required pumping more than 4 times in the last ar NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or pri s below high ground water elevation. Any portion of cesspool or privy is wi in 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or pri is within a Zone I of a public well. Any portion of a cesspool or ivy is within 50 feet of a private water supply well. Any portion of a cesspool privy is less than 100 feet but greater than 50 feet from a private water supply well with no ac ptable water quality analysis. [This system passes if the well water analysis, performed at a DE certified laboratory,for coliform bacteria and volatile organic compounds indicates that th ell is free from pollution from that facility and the presence of ammonia nitrogen and n' rate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggere .A copy of the analysis must be attached to this form.] /1,,o (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a d ' n flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the c ' eria above) yes no _ — the system is within 400 feet of a surface ' tng water supply — _ the system is within 200 feet of a trib to a surface drinking water supply — the system is located in a nitro sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water su y well Ifou have answered"yes"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: Owner: Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No — Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? — Has the system received normal flows in the previous two week period? -.0 — Have large volumes of water been introduced to the system recently or as part of this inspection on . 1 — 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? A _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition &—baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no — Existing information. For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1--S—P 21V_61,2L Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): SyS� �Vor k-co n�,ovt,dLc! Lr 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): AZ Water meter readings, if available(last 2 years usage(gpd)): ,._ Sump pump(yes or no): G` cl, „ Cd Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes no):_ Non-sanitary waste discharged to the e 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ,,(t-yle < Was system pumped as part f the inspection(yes 6r no): n/ � If yes, volume pumped. allons--How was quantity pumped determined? t�►i �- Reason for pumping: TY E OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 4./ 6 Page'7 of I I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,l S 73 Ow -C Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: , I Materials of construction:_cast iron _40 PVC_other explain): Distance from private water supply well or suction line: 1U111 Comments(on condition of joints,venting,evidence of leakage,etc.): Ze— n �rlc u • ,def v�cl. SEPTIC TANK:Z(locate on site plan) it Depth below grade:_ Material of construction: /concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) � Dimensions: (� C�=� / 0 5 Sludge depth: ,��c" Distance from top of sludge to bottom of outlet tee or baffle: IB N Scum thickness: Zd " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:1, ' How were dimensions determined: Ldr-P fooL cot/i 6�n to Comments(on pumping recommendations,i9let and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leaka e,etc.): rg7 e r o GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass olyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of/inlet : Distance from bottom of scum to boor baffle: Date of last pumping: Comments(on pumping recommenutlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ./.y,9 Dfv� Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal erglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: Ballo ay Alarm present(yes or no): Alarm level: Alarm in king order(yes or no): Date of last pumping: Comments(condition of al and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on sitelan P ) Depth of liquid level above outlet invert— .4/-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. f Wo v —,- „v _ PUMP CHAMBER: (locate on site plan) V Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,con ' on of pumps and appurtenances,etc.): 8 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_SS9 Owner: 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: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): w Y+ vP7vcL,Stfi- 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 Comments(note condition of soil,sig of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic f ' ure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /5"8 0/,'j2Ze tj� Owner: Date of Inspection: 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. !S r a sy 34` 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: /S a".•�%G Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: y / 11 Bill Date: 01/06/99 Account count#: 01-4638000-0 TOWN OF NORTH ANDOVER Bill#: 0011279 Due Dat . 02/05/99 : Water and Sewer Bill i - SVC Addr: 1 �:::...: :.:...:::.....:.:.:.:....:.:..:::::.:.....:. . 58 OLYMPI N b.t Mtr Previous Present Bill ID Date ReadingDate ReadingCode Usage Water Sewer 001 . 8/28/98 3264 12/02/98 3302 EST. 38 $103.74 0.00 103 .74 3t 1; NEW WATER RATE IS $2.73 PER 100 CF. Previous Balance $0.00 x SEWER RATE REMAINS $2.75 PER 100 CF. Penalty Charge $0.00 UNPAID BALANCES WILL BE SUBJECT TO 14% INTEREST Interest tal.I�lT@............::::::::.::::::. 10 3 .7 4 Kaon thic..n.t7nn fnr..no.ro�n.Ar . Bill Date: 09/15/98 TOWN OF NORTH ANDOV Account#: 01-4638000-0 Bill #: 0011279 Due Date: 10/15/98 Water and Sewer Bill Svc Addr: 158 OLYMPIC LN Mtr Previous Present Bill 3 ID Date ReadingDate Readin Code Usage Water Sewer — J 001 5/14/98 3166 8Z28/98 3264 ACT. 98 $254.80 $0.00 254 .80 CURRENT WATER RATE$2.60 PER 100 CF. Previous Balance $0. 00 CURRENT SEWER RATE$2.75 PER 100 CF. Penalty Charge $0. 00 Interest $0. 00 <:: > >< ��.Due............:.:.::::::.::.:.:...:.:::. 254.80 Kee,tbj_, n 'i .f9T vppr records Bill Date: 05/22/98 Account#: 01-4638000-0 TOWN OF NORTH ANDOVER Bill #: 0011279 Due Date: 06/22/98 Water and Sewer Bill Svc Addr: 158 OLYMPIC ...........................:::::::::. �#.k )Ft >`> >::>:>::::«:>s: Mtr Previous Present Bill ID Date Readin Date Readm Code Usage Water Sewer 001 3 12 98 3132 5/14/98 3166 EST. 34 84.66 $0.00 84.66 CURRENT WATER RATE$2.49 PER 100 CF. Previous Balance $0.00— CURRENT SEWER RATE$2.55 PER 100 CF. Penalty Charge $0.00 EFFECTIVE 7-1-98 WATER RATE WILL BE$2.60 AND T..#........+ �. Bill Date: 06/15/99 Account#: 01-4638000-0 TOWN OF NORTH ANDOVER Bill,#: 0011279 Due Date: 07/15/99 Water and Sewer Bill Svc Addr: 158 OLYMPIC LN ` :;::;i'';j:•i:}�i?:!':':Yi.:.,,:..;:;v:::Kiii:;C;:::: ::::':::� i:::::i::iiiiii:ii:i: ji:ij;ii:ilii: '::i::::......:...!:::::::i:::::::i:::ti ;:ti:::'i:':':.::. •.il'{1N![d''. :�M{':: ©::':': i:•::::ij:i:'i`i:CC:i::ii;::;j j::i::ii::::?:':':•::•:::::i:•:::::':'::::?:�i::::::ii C ............................................................... Mtr Previous Present Bill Usage Water Sewer ID Date Reading Date ReadinR Code 001 3/26/99 3339 4/15,/99 3345 ACT. 6 $16.38 $0.00 $16 .38 "Beginning July 1st, a new billing system will Previous Balance $0. 00 be put in place. You will be billed quarterly Penalty Charge $0 . 00 on a 3-month staggered schedule. Your next bill Interest $0.00.. williv r a r e either Aug 15 Sep 15> or Oct 15". D $16 .38 � Bill Date: 03/20/98 TOWN OF NORTH ANDOVERccount#: 01-4638000-0 Bill #: 0005928 Water and Sewer Bill Due Date: 04/20/98 Svc Addr: 158 c OLYMPIC LN Mtr Previous Present Bill ID Date Readin Date Readin Code Usage Water Sewer 001 12 08 97 3099 3 12 98 3132 EST. 33 82.17 0.00 82.17 Previous Balance $0.00 Penalty Charge $0 . 00 Interest 0.00 "' ;:.;;:.;;: 8 2 .17 s ' ! 3 ; ! z 3. ! 3 !fin r .................. �, •,Y. .. k�lot ! LF�kNfh�G� ©LymptC LAW E a E E6END� dENGHMAeV-: NOTES: AN �rn.�i.. •.r.. _.�-- - t ,I i P� or. L�ACN11"KKa bta 5U6SURFAGE D15POSAL SYSTEM D�l6N MO SCA-Le FOiI. L.Orr: c S-r¢r_r--r: Torrid` tl!'F:Tlt .�t'S^.'J�arR JiY a I PREPAitTsC FOQ -�—+PegGaDC4rfE17 PIo'E 1 �l L=ANF C)LLNI 2, — —_— '"�""'+e,, FIiA,NIL G•4GL.INAS�A�..f OGIATC.S — � ; ENdIIVCE¢'6 � AaGH1TL'G'rS A , 451 Awoov Q S-rcZEST $Love•-005 —r O ^' NOitTH AtJDOn/EQ,N1A. r 'y. ALL ENDS CAGGeo :V. , E ;°1 u�. �-i I c 61 DESIGN DATA j CALCULATIONS SOIL O BS E R VAT IONS by !� AERCOLA7 low-TEST NO. -�'- - .2 .... 3" 1 �'l �'oP-ELEVATIpN _ T —_ ?tE: ALL Gro Pm,w6 Sew..-be 4'4- l<-WevUL&40 PVCA,57M.D-ZZ4109L BOTTOM_E IE VAT ION _ - t-�1,;,Q 7�� 1----._ _ 4 10N -MINS. I f3rr. Flbae C II<o-sa. `- '12..-►9" DROP-MIrtS. - - ---'-�--- --- - `• __ DFLOP-NA%t45. - t✓ _ - - — 1 t i PERe_RACT E_Mill./IN- T SOIL PROFILE-DEEP PIT No. —1 — 2 3 4 5 w ! DATE — \ ToP-ELE VATtON i -TOPSOIL �J Ski SUBSOIL �- ARENT SOI P t2"Mw Dove¢ WATER TABLE WCgNETr G2USNt0'S"fOT1E ��Ey{;� 114 ,�T -rZ wn Eo cwrs►11'n s.mo,4e I WATER TABLE ELEVATION i i1']C�c,;.�.z Q'A�LS"�4TiG'�TAlil4 , �JBt?'• pr _GppF�pW X �,3C$F�6�Otis kCJ SF F3£tiD i.lSi rl l Jo �F. i � 9 P �' (,,,E1.GWlN6 Fll4LD P�O>"l4E ` NO SCALE " SCNE!MATtc ONLY --r _a TOP OF cN0 NOTE' ALL ELEV4TIOt-4- WVL`RT OF PIPE. FILL. QER+UIQEMENT6 `p �`r: SLOPE USEO; i �y F G.= 1 GC.bAWG�1'fS@ TEES MIN.SLOVCa -p2+, —i 4"G Z TELE:S AU.e6S G HIMN["(TO W tTHIN + 4`Oc KNISH C7¢A17E t '1'-CI MIN. �I PAPE �I�T¢IDUTION �X coo.,...,.w�i --- S'-02 __:l•..-r: .: •' 3= .009 ' t� `GAL.�pyrlCThNIG ` e '. I { al Ij - d V N s r r owcY.No. D-1 tum Board ofealth North An vergNass. SEPTIC SYSTEM ' -i; INSTALLATION CHECK LIST LOT Td s MOPID DATEDISApFRdVED XCAVATI OK _r L easansf ;0 7j -I-V FAIL 00, 1. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PVC Pipe 4. Septic Tank a. Tess - Length & To Clean out Covers b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions ` b. Stone Depth ' c. Capped Eads d. Clean Double Washed Stone 7. Leach Pit a. Dineksions b. Sto a Depth c. ash Pads d. eAs e. Gwent Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Tinel Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location With Regard-to Pere Test d. Elevations e: Water Table SUBSURFACE DISPOSAL SYSTEM CHECK LIST Lv 7- NORTH NORTH ANDOVER BOARD OF HEALTH �f ATE PROVIDED DISAPPROVED DATE TIME REASON 1YI179 Title Reg. 2. 5 Fail OK The submitted plan must show as a minumum: _(-a° the lot to be served (area,dimensions ,lot #,abutters) Planning Board files) location and log of deep observation holes-distance o ties location-'and results of percolation tests-distance o ties .d design calculations & calculations showing required -' ' leaching area . ( location and dimensions -ef system (including reserve __-a,pea) ),� isting and proposed contours ,,,(-g") location of any wet areas within 100' of the sewage disposal. system ot- disclaimer (check wetlands mapping) surface and subsurface drains within 100' of sewage • , isposal system or disclaimer _� location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board Iles) known sources of water supply within 200' of sewage isposal system or disclaimer location of any proposed well to serve the lot (100' -from leaching facility) location of water lines on property (10' from. leaching- facilities) - '� cation of benchmark �( iveways )garbage disposers o PVC is to be used in construction I profile of the system (elevations of basement, plu/ I `J pipe septic tank, distribution box inlets and outle" I istribution field piping and any other elevations) i( maximum ground water elevation in area of sewage di "_�s ystem Cs,) plan must be prepared by a Professional Engineer or j other professional authorized by law to prepare such ' plans S Septic Tanks } Reg. 6 �(,a')Capacities - 150% of flow, water table , tees, dep i of tees , access, pumping, (b ��"J�leanout - 10' from cellar wall or inground swimming pool X25' from subsurface drains NorthLAndover Subsurface disposal system check moist - Page 2 ail OK Distribution Boxes Reg.10.21 ope greater than 9.08 Reg.10.4 Sump Leaching Pits Leaching pits are preferred e the installation is possible Reg.11 .2 (a) Calculations of leaching area (minimum 500 S.F. ) Reg.11 .4 (b) Spacing Reg.11 .1 (c) Surf ac Spacing 2% , ieg.11 .11 d) Cover material Leach ,ng Fields Reg.15.1 .aljreater than 20 minutes/inch Reg.15.1 Area (minimum 900 S.F. ) Reg.15.4 �� jGonstruction of field Reg.15.8 surface drainage 2% Reg. 3.7 from, cellar wall or inground swimming pool Leaching Trench.s Reg.14.1 (a) Calculat ons of leaching area (min. 500 S.F.) Reg.14. 3 (b Spacin (4 ft. min. 6 ft. with reserve between) Reg.14.4 (c Dimensions 14. 5 , Reg.14.6 (d) Construction Reg.14.7 (e) StWne { Reg.14.10 (f) rface drainage 2% Dow ill §12pe �(a�lope y/x = (to be shown) Tb) y/x X 150 = (to be shown) Pum-pa Reg. 9.1 (a) Approval Reg. 9.6 (b) Stand-by power