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HomeMy WebLinkAboutMiscellaneous - 16 CARLTON LANE 4/30/2018 (4) 7 Commonwealth of Massachusetts u w City/Town of North Andover a W° System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the in must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351, A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tato 16 Carlton Lane key to move your Address cursor-do not North Andover MA use the return City/Town State Zi Code key. p 2. System Owner: Murphy Name renin Address(if different from location) _ City/Town State � Zip Code b ' Telephone Number B. Pumping Record 1. Date of Pumping *7 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0 Vo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: ksl _ '4 ezP 2,,- Name Vehicle License NumIFvi t Stewart's Septic Service , Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 S f Date gn t e of Receiving Facility Date t5form4.doc•03/06 System Pumping Record.•Page 1 of 1 �OVER:..MASSA Fwfl,I /�,:1 e.��o rd REC '�'' ��Il��,l,f/1�;,• 11,�rq�,�ll��, �l , her piovldod Wo loan for �Ilp ;acur 800rcl or 1 g 2009 �c �'.bm111o010 JU4 111Y IOC 11 8^er(: / Ue':^ (' n oo (n or oinor !p?ro;l, l .1n ri A, Facility Inform�llon ry N OF NORTH ANDOVER HE SYS Qm lQu on.- rd : r;, ,� 1'(L/,'i!.'('•2rsy318m oWnOP,'�' '',�'. . . . , ti ' dlµ( 'Al 1cYn buVon� I_71011 ate, r81,-Pumppinq Pa'yord ' oco 9" ump,ln9.� i: 6 w •• �' , �rYPo 41 iy�(om,',. � � n':dl"•'r r ,6'' ���. • �. mvon,li roe Flllo('P�p,,�onl? r' Yos n'o '1,�'�;�`:���!��J•`111,.,',i;11,,'�J,;I�,j`11,,(,.,�. ,�. II yey Sy 8�m� pympod 8y: ' ',,• �;,•�, � ,1111 �• ��G ; 41 + ;;Y;`��y'! f(11'�i i1 .Y1r• ! 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No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 RE, Date Name & Address Gallons Comments 1-M4,Patter reality 81 Sawmill Rd 1600 Good TOWN OF NOUH ANDOUg.i� 2-May^Mulcahy 350 Sharpners Pond Rd 1500 Good HEALTH DEPART FNT ;,Greene'62 Willow Ridge Rd 1000 Good 3-May,inro4059 Grandville 2500 Good 4-May;R,ncon;115 Sherwood Dr 1500 Xsolids HG 9-May Calla�hn'940 Foster St 1500 Good 10-MWMelerim 1444 Salem St 1500 Xsolids 15-May:Diraffel 3 Brenkin ridge Rd 1500 Good .Depari,175 Stone Cleave Rd 1500 Good 16-May Martin 701 Forest St / 1500 Good " Murphy;16 Carleton Lane 1500 Good 18--May Vandergraaf 267 Old Cart Way 1500 Good 8dlano,2198 Tnok St 1000 Rh 21-May Yomicho�115 Laconia Cir 1500 Good Reti 42 Cross Bow 1500 Good 24-May\'Carbonell 1560 Salem St 1000 Good 29-May Thurber 210 Farnum St 1500 Good ,,31-May;ClearyA05 Wintergreen Dr 1000 Good Of,NORTH 1N t Y * 6147 F p • Town of North Andover HEALTH DEPARTMENT SACHUSt CHECK#: DATE: L v� LOCATION: H/O NAME: 1 CONTRACTOR NAME: Type of Permit or Licens . 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) $ ❑ Title 5 Inspector/ $ CYTitle 5 Report $ �✓" ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink- PP Treasurer J&S DEVELOPMENT CORPORATION 10961 Toikn 6f North Andover 06/15/12 100.00 >z o L ` =� 4Q cr-UJ % ) LL= im oj s1 z w O� -------------------------- Haverhill Bank (872=Cariton �81Saw�mfllitle 5 Fee 100.00 e Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Carlton Lane Property Address (/ Kristine & Christopher Murphy _ Owner Owner's Name — information is No Andover Ma 01845 6/12_/2012 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:When A. General Information filling out forms on the computer, _ use only the tab 1. Inspector: RCP–IVUD key to move your cursor-do not John DiVincenzo use the return Name of Inspector UN 2 d-4t U I key. Stewart tic Service Comp r� Companyy Name YN OF TFf Al*fDZSVER HEALTH DEPARTMENT 58 South Kimball _ IIIIIIP Company Address r Bradford _ _ Ma 01835 City/Town State Zip Code 978-372-7471 _ S113386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails /RN d Furth r Ev u ion by th ocal Approving Authority C 6/12/12 s Signature Date The system inspector shall submit a )Yof 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 16 Carlton Lane Property Address Kristine &Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'c 16 Carlton Lane 4M Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 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 distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 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 ;M 16 Carlton Lane Property Address Kristine &Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 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, 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 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 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 16 Carlton Lane Property Address Kristine &Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 16 Carlton Lane Property Address Kristine &Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 ppl Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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 the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 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 16 Carlton Lane Property Address Kristine &Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: No Andover BOH Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? site guage on truck Reason for pumping: inspect tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11110 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 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 11/23/1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2'-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: Sludge depth: l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town 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 30" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure,sluge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both tees in good shape , liquid levels good, no leakage Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 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 ;M 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Dist box, good condition, no leakage, no soilds. Carry over equal dist. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I i t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/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: 4-50' ❑ 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.): No Hydraulic failure, no ponding , no damp soils Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/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 j at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ,•''y 16 Carlton Lane Property Address Kristine & Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water' 4 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: Nov 23,1999 Buliding permit, As BulitDate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Pulled Files ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: System 3' to 4' above water table Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 16 Carlton Lane Property Address Kristine &Christopher Murphy Owner Owner's Name information is required for every No Andover Ma 01845 6/12/2012 page. City/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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �l APPROXIMATE EDGE OF POND ry� POND PROPOSED ry 10'x12' DECK-----; INGROUND w l cN POOL rrli PROPOSED 12'x12' SUN !'�! ROOM TO BE BUILT ON / EXISTING DECK E i D' ZONING DATA REQUIRED SETBACKS FRONT = 30' SIDE = 30' REAR = 30' o��tP�`N PROPOSED BUILDING PERMIT PLAN OF 41 4 ��9cyGREGORY N 16 CARLTON LANE L NORTH ANDOVER, MA. BOWDEN `^ #34610 PREPARED FOR: A90FES AV EDWARD MCINERY, TRUSTEE OF GF REALTY TRUST DATE: NOVEMBER 23, 1999 . SCALE: 1" 40' Northpoint ov survey ,5'en ces � 180 Kater Street Haverhill AU 01830 j1978J-372-08.9S 28 3gg, P \ R=25.00' L=28.81' nNG � ;TY .LING 6 I Ulr o � 0 O Z N y X00, JOB NO: 2884 0 RT� AlJDO � q Reco JUL6rd � •' -I. o 2008 'i .r•"f�JO�I'1�yM1J'�'I :tAt�11��1. �J11�,1�(�rr�l' ry' (j .�(,•:..,t VVt(�I+J. ,�I�tI,SJ���,1�"�'r�'Irll.�n: t(�� �II{� �e lil�tJ:�Y.,,r. ' r 11,1; .{.rtjl (�)'I'tl f'iF7;11'rl•. �''� �EP..ha# provided jhh form for use by local Board# TOWN H_ IUTHVb�� 's e P pin� be aubmlt�ed fo the local Boara of Health or other a r T PProv ng author ty, Ai Facility Inforr atIon „„�m Ro run l.',; � .t•I y'. ` ouV ..t Systam Lt>uUon: aNy the ltD koy AvviV;4 tu+ tl a CC v ' ':I/' ,',( �'"i.',i,�'Nuns';/'i::ir,� ;•,�••'"t Irl: ,.•: ,.�.., / ln'�yy7/� • '� !�'. t ?'1 ..:r i ' �,1, .I� ,,r t J V��'�///Cry ri Addroti (If 004(tnt rom b cation CktyRown l elopnone NumOor " ump 111g;Regord. 'R � -- •,, .I/t't:�yl�ti�.r7r;•.4,lJn,t,:r)'li-l�'{���t(,�'•yl "1 `.��Z ' 1, Date o( Pumpin� ` oat, : I 2. QuanU ryP umped: G�ponJ 31 `Type 9f syatsm;*, Cesspools) pecic Tank Tight Tank " (�JOther(dsscdba il/!rli, i,�•,J•r;)��'•,�•1, 4 EMQQi ! Tae F1IIq(pf�.Osant? Yes o I� I\•(,it.lr�`( , .❑ � yes, was If Cleaned C] YOS • (p�' .;;Y.:S 11'.'1�J'.r:l','j 'f�' rig :l'i,.r.� !'� 1!,� /`i�r/ •.._1 PYmpOda y.'' I.• G --- !�," 1,a. '•,ln:l..J.v, / •1 r I .fd �- Pr.�,. J:T;�' LOCB On.Wh8.r8 COQIenL3 d'a "1`',�,Ij.�t l'1.' , (7Y-`•N...��tlf l" :il lr„ ,w8�8 Ir OW: , r �. t I i .S'..(JI Ir ,,/,.�r, �' .II;'"..�:. ���,,�' tr'.�Sri i•,:,{},.• i� � � h• m ' )� S3. OV/ 8 deals /e nova s% IN�^rl.Co.'0.aJQS '-- . . , Syltam Pumping Recory ;; � P �� Svti rCo 3 r u,1 eQr i- G, " r v Sill FORM U - LOT RELEASE FORM 4/'( /01-- INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTIO APPLICANT_ s �� rny r (,�y PHONE -8'029 LOCATION: Assessors Map Number 10'7 /q PARCEL 00 SUBDIVISION LOT(S) STREET_ C Q�°kj.kU e ST. NUMBER OFFICIAL USE ONL CO ErMINISTRATOR F TO EN C NSERVAT DATE APPROVED i P l i DATE REJECTED 4C AeAj COMMENTS s Scl TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED C/J "S P IC INSPECTOR-H TH DATE APPROVED �)� DATE REJECTED COMMENTS ---- - PUBLIC WORKS-SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE,__ ROVWW M jm TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT RLP RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING .� BUILDING PERMIT NUMBER: DATE ISSUED 7 3 SIGNATURE: Building Commissioner/I or of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: C CAR(--+orj LA ue oO© I f Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District proposed Use Lot Area Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided C 1.7 Wats Supply MGL.C.40. 34) 1.3. blood Zone iufanmtion: 1.8 Sawense Disposal System: Public ❑ Private ❑ zase Outside blood Zane ❑ Municipal ❑ on Site Disposal System ❑ � SECTION 2-PROPERTY OWNERSE00AUTHORIZED AGENT t f t i; i iz t r Ct: ,!ra3 NO IT 2.1 Owner of Record e k 1-rs 4-0 p k e r r u f p�y 4)0. .4 "V Cay- l'VW Name(Prin Address for Service Signature fTelephone 2.2 Owner of Record: C Name Print Address for Service: 2 Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable r� Licensed Construction Supervisor: C License Number "T Address Expiration Date 3 Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number M r Address r snow Expiration Date z Si nature Telephone G1 t°RTh TOWN OF NORTH ANDOVER ;``" ".4 OFFICE OF ' a BUILDING DEPARTMENT + 400 Osgood Street 40�•e�,;,o:� �F North Andover, Massachusetts 01845 D. Robert Nicetta, Telephone(978)688-95454 Building Commissioner Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: 5 3//0 5 JOB LOCATION: L Number Street Address Map/Lot HOMEOWNER CHrI Mutpkq q-1 - zs-9 go 2-q 0179--6z/-5-(,f — Name —T Home Phone Work Phone PRESENT MAILING ADDRESS /(o C'�}2GfJC-gvy� 41 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE I 7 7 APPROVAL OF BUILDING OFFICIAL III).\Rl)Oi ,1CNE;.\LSiiXR!15.11 CONShRV\TION689-95 0 IIHAL1,11G3X=,9510 IT,\NNIV;uR1:)s35 r APPROXIMATE EDGE OF POND ry0 POND D p�HD 'r' yr '(POSED #' '10'x12' DEC': N INGROUND , �( POOL {, . 0 PROPOSED 12'x12' SYN ;LOOM TO BE BUILT CNJ rXISTING DECK / EXISTINC 2 STY DWELLINi #16 ZONING DATA REQUIRED SETBACKS I \ FRONT = 30' 3S9 9 SIDE = 30' REAR = 30' _ PROPOSED BUILDING PERMIT PLAN �tA��" of *14,r'r 16 CARLTON LANE � GREGO cy� L NORTH ANDOVER. MA. sowoEN ^ rt3a610 PREPARED FOR: p"0es o`'A EDWARD MCINERY, TRUSTEE OF GF REALTY TRUST as DATE: NOVEMBER 23, 1999 SCALE: 1' = 40' Northvoint CN SWWOY Services � >BO Kater Strwet ffaverhil4 AG! Of&?a R=25.00' L=28.81' 1 I �7 0 C� NN Z s "O J08 N0: 2884 A7n P. K �,yt. 1855 � ' ciiu5��," ryyAyy�� TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NOTICE OF DECISION Date . . .November.19s. 1973. . . . . . . Petition No.2.4"'.� .. . . . . . . . . . . . . . . Date of Hearing. .49vew!�er .2.2t.1973 ona Petitionof . . . �?ich x . �.. . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Premises affected. C.. ..c;tcn ..a. . . . . . . arla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Referring to the above petition for a variation from the requirements of the . . . . . . . . . . . . . . . . . Northiult av,r ��t�71""1� W;�--'.�;�s Sea. L Taa�.o ;L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . so as to permit . .44.ofcLaawa;444� �4a r thanraft -14'at;it; aide lot Une . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . After a public hearing given on the above date, the Board of Appeals voted to . 91-UNT. . . . . the lci2'3 i�1�L"6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . for the construction of the above work, based upon the following conditions: Signed Dr. Zugenad. Bel iveaut Acts; Chairman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . tv illiasn l3. SUewe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LOLi�ra . . . . . .U. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' .:rod L. �°`rize!:Ler f Esq., Associate Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J&mas D. Nobles Jr.I Associeve I:8,1iuez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Board of Appeals •r . ORTN .i 1 f}•'i5 �iVVY R TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS November 19, 1973 John J. Lyons, Town Clerk Richard Noonan Town Office Building 16 Carleton Lane North Andover,, Mass. Petition No. 24-'73 Dear Sir: A public hearing was held by the Board of Appeals on November 12 1973 upon application of Richard Noonan who requested a variation of Sec. 9.3 and Table 2 of the Zoning By-Law so as to permit an existing dwelling closer than 30 feet to the side lot line; located at the west side of Carleton Lane; approx. 200 feet from the corner of Raleigh Tavern Lane and known as 16 Carleton Lane. The following members were present and voting: Dr. Eugene A. Beliveau, Acting Chair- man; William N. Salemme, Louis DiFruscio, Alfred E. Frizelle, Esq., Associate Member and James D. Noble, Jr., Associate Member. The hearing was advertised in the Lawrence Eagle-Tribune on October 27 and November 3, 1973. All abutters were duly notified by regular mail. Atty. Frank J. Pitocchellit of Methuen, represented the petitioner. He explained that the Noonans purchased the home last year and upon having the property surveyedt found that the garage was located approximately ten feet from the side lot line. The dwelling in the adjacent lot is located approximately 50 feet from the lot line thereby leaving 60 feet between dwellings which would be within the intent of the By-law since the setback requirements for an R-2 area are 30 feet. It would be a great expense to the petitioner to rase the garage and remove it in order to comply. The same builder built both homes. He feels there may have been a problem in locating the house for the septic system. Building Inspector Foster explained that many lots in this development were changed around by the developer and that when he inspected the building it was in the winter and covered with snow so that the stone bounds could not be located. There were no abutters present and there was no opposition. Atty. Frizelle made a motion to GRANT the variance; Mr. Salemne seconded the motion and the vote was .unanimous. The Board found that there would be a hardship and expense if the garage were razed; that the intent of the By-law was met in that there are at least 60 feet between buildings. Very truly yours, BOARD OF APPEALS Dr. Eugene A. Beliveau, Acting Chairman AD THE COMMONWEALTH OF MASSACHUSETTS 264 NORTH...A=....................................................... ctrr OR TOWN BOARD OF APPEALS -November 14,._ - ..19 73 ------------------------- ..... -- NOTICE OF VARIANCE Conditional or Limited Variance or Special Permit (General Laws Chapter 40A,Section 18 as amended) Notice is hereby given that a Conditional or Limited Variance or Special Permit has been granted To..._..Richard Noonsn------------------•---•--.........•..--••----------•---.....................•....._....._._....._.........••---- Owner or Petitioner Address......16_ Carleton Lane -------------------------------------------•--------------------•-----------------•--------------------•---------- City or Town.......North Andover, Klass. 16 Carleton Lane ....................•-----•--•-•..-•-- ----•----••----•-----••-----•--••-•-•••--...._._....•----....__.....__...._..------•----••------•• Identity Land Affected ......-----•---••....................••-----------......--....--------...---•----------•-^•---....----^---------................--_.............._... North Andover -.._.Board of Appeals affecting the by the Town of-------------- ---------------------------------------------------•---- rights of the owner with respect to the use of premises on. - 16 Carleton Lane North Andover Mass. .................•-_.... .... ..............._............_._..._..---.._...--••--•-•--•-• •-- -----•-••-.....f------•-•----•--•--------- Street City or Town the record title standing in the name of Richard 8c Kathleen Noor 1 a.4,--hllabJAt3..._$s__WjAe___________________________________________ 16 Carleton Lane, North Andover, Massachusetts whose address is.---- •-------------•-----------•----------•--------------------------------------------•---- Street City or Towd State by a deed duly recorded in the----A5TW Essex-------------County Registry of Deeds in Book _12M..... Page...2-----------� .................................................... Certiticate No..................................Book ................Page---------------- The decision of said Board is on file with the papers in Decision or Case No.._u 73_........ in the office of the Town Clerk..._.__.___.North Andover, Mass.. ---------•--•-•----------•....................... Certified this_.1 Wday of..............November..................19 73 Board of Appea Acting Chairman Be t Appeals --- • . • . •••... . . . .. .. .. ......................Clerk Board of Appeala (1 ' 7���7� and - . ---'-- „� •-._..,..r 19........ Q�-------------- �.'it7C1[ ._.'..--'---'...................Minutes ._..1Y1. '_---•--- ------- ........................•...--.....•.•...••........__..._._...___......._... 1 Notice to be recorded by Land Owner. FORM 1094 M6888 & WARREN. INC.. REVISED CHAPTER 2/2•I962 APPROXIMATE HEIGHT OF EXISTING BUILDING co I MAXIMUM RIDGE HEIGHT OF / \ I / \ PROPOSED NEW ADDITION 11/ N L ENLARGED ROOM +i i - - - - - -iY-- - - - - - - - - o I I II NEW DECK O0 t 12' �I CN I L _ - - EXISTING SUN ROOM I I ENCLOSE EXISTING + 12 I I PORCH FOR NEW I �— '—�' vEXISTING co I I MUD ROOM I EXISTING DECK +i POOL DECK II I II II II TRANSVERSE SECTION AT PROPOSED NEW ADDITION SCALE: 1/8" = 1 '-0" MARCH 3, 2003 MURPHY RESIDENCE, 16 CARLTON LANE, NORTH ANDOVER, MA IN 29 NORTH MAIN STREET, IPSWICH, MA TEL: 978-356-0467 FAX: 978-356-1024 i vo C.t a'%4 � 6 y � } j J ZI x ZI oo i 1 �. Woo ? " e " six al� -A,l,.�al s , ►�p�l/'rv' aqqv-)--4)z+�) `)1 ?.ry. 0 Q s w ' � � A N � � tdor, xt"� inf No c�A1J es 2 9 BeamChek v2004 licensed to:David Mehlin Reg#4151-64920 MURPHY RESIDENCE N.ANDOVER, MA FAM. ROOM BEAM Date: 3/22/05 Selection F-(3) 1-3/4x 9-1/4 1.9E TJ Microllam®LVL Conditions Min Bearing Area R1=4.2 int R2=4.2 int Data Beam Span 10.0 ft Beam Wt per ft 12.48# Reaction 1 TL 3750# Reaction 2 TL 3750# Bm Wt Included 125 # Maximum V 3750# Max Moment 13593'# Max V(Reduced) 3432# TL Max Defl L/240 TL Actual Defl L/306 Attributes Section (in 3) Shear(int) TL Defl (in) Actual 74.87 48.56 0.39 Critical 60.56 17.75 0.50 Status OK OK OK Ratio 81% 37% 78% Fb(psi) Fv(psi) E(psi x mil) Fc-L(psi) Values Base Values 2600 290 1.8 900 Base Adjusted 2694 290 1.8 900 Adiustments CF Size Factor 1.036 Cd Duration 1.00 1.00 Cr Repetitive 1.00 Ch Shear Stress N/A Cm Wet Use 1.00 1.00 1.00 1.00 Cl Stability 0.0000 Rb=0.00 Le=0.00 Ft Kbe=0.0 Loads Uniform TL: 400 =A Point TL Distance B=3375 5.0 Uniform Load A Pt loads: 0 R1 =3750 R2 = 3750 SPAN = 10 FT Uniform and partial uniform loads are lbs per lineal ft. Notes BEAM CARRIES POST FROM STRUCTURAL RIDGE BEAM, SHOWN AS POINT LOAD OF 3,375 LB. BeamChek v2004 licensed to:David Mehlin Reg#4151-64920 MURPHY RESIDENCE N.ANDOVER, MA FAM..ROOM BEAM Date: 3/22/05 Selection F-(3) 1-3/4x 9-1/4 1.9E TJ Microllam®LVL Conditions Min Bearing Area R1=4.2 in R2=4.2 in Data Beam Span 10.0 ft Beam Wt per ft 12.48# Reaction 1 TL 3750# Reaction 2 TL 3750# Bm Wt Included 125# Maximum V 3750# Max Moment 13593'# Max V(Reduced) 3432# TL Max Defl L/240 TL Actual Defl L/306 Attributes Section(W) Shear(ink TL Defl(in) Actual 74.87 48.56 0.39 Critical 60.56 17.75 0.50 Status OK OK OK Ratio 81% 37% 78% Fb(psi) Fv(psi) E(psi x mil) Fc-L(psi) Values Base Values 2600 290 1.8 900 Base Adjusted 2694 290 1.8 900 Adiustments CF Size Factor 1.036 Cd Duration 1.00 1.00 Cr Repetitive 1.00 Ch Shear Stress N/A Cm Wet Use 1.00 1.00 1.00 1.00 Cl Stability 0.0000 Rb=0.00 Le=0.00 Ft Kbe=0.0 Loads Uniform TL: 400 =A Point TL Distance B=3375 5.0 Uniform Load A Pt loads: R1 -3750 R2=3750 SPAN= 10 FT Uniform and partial uniform loads are lbs per lineal ft. Notes BEAM CARRIES POST FROM STRUCTURAL RIDGE BEAM, SHOWN AS POINT LOAD OF 3,375 LB. BeamChek v2004 licensed to: David Medlin Reg#4151-64920 MURPHY RESIDENCE, N.ANDOVER RIDGE BEAM Date: 3/16/05 Selection L(3) 1-3/4x 11-114 1.9E TJ Microllam®LVL Conditions Min Bearing Area R1=4.2 int R2= 4.2 in' Data 1 Beam Span 18.0 ft Beam Wt per ft 15.18 # Reaction 1 TL 3737 # Reaction 2 TL 3737 # Bm Wt Included 273 # Maximum V 37374 Max Moment 16815'# Max V (Reduced) 3347# ! TL Max Defl L/240 TL Actual Deft L/247 Attributes Section (in') Shear(in') TL Defl (in) Actual I 110.74 59.06 0.87 Critical 76.93 17.31 0.90 Status ; OK OK OK Ratio 69% 29% 97% Fb (psi) Fv (psi) E (psi x mil) Fc (psi) Values rBase Values 2600 290 1.8 900 Base Adjusted 2623 290 1.8 900 Adjustments CF Size Factor 1.009 Cd Duration 1.00 1.00 ! Cr Repetitive 1.00 ! Ch Shear Stress N/A Cm Wet Use 1.00 1.00 1.00 1.00 Cl Stability 0.0000 Rb = 0.00 Le= 0.00 Ft Kbe = 0.0 Loads Uniform TL: 400 A Uniform Load A R1 = 3737 R2 = 3737 SPAN = 18 FT Uniform and partial uniform loads are lbs per lineal ft. Notes NOTE, RIDGE DESIGNED AS STRUCTURAL BEAM TO ELIMINATE REQUIREMENT FOR COLLAR TIES BeamChek v2004 licensed to: David Mehlin Reg#4151-64920 MURPHY RESIDENCE. N.ANDOVER RIDGE BEAM Date: 3/16/05 Selection ( (3) 1-3/4x 11-1/4 1.9E TJ Microllam®LVL Conditions Min Bearing Area R1=4.2 int R2= 4.2 int Data Beam Span 18.0 ft ----- �--------- - - - Beam Wt per ft 15.18 # Reaction 1 TL 3737# Reaction 2 TL 3737 # Bm Wt Included 273 # Maximum V 3737# Max Moment 16815'# Max V (Reduced) 3347# TL Max Defl L/240 TL Actual Defl L/247 i �---- -- — ---- --------_..---------- Attributes Section (in 3) Shear(in') TL Defl (in) Actual 110.74 — 59.06 0.87 Critical 76.93 17.31 0.90 Status OK OK OK Ratio 69% _-- 29% 97% Fb(psi) Fv (psi) E(psi x mil) Fc-L(psi) Values Base Values 2600 290 1.8 900 Base Adjusted 2623_ 290 1.8 _900 _ Adiustments I CF Size Factor 1.009 I Cd Duration 1.00 1.00 Cr Repetitive 1.00 Ch Shear Stress N/A Cm_Wet Use 1.00 1.00 1.00 _ _ 1_._0.0 _ Cl Stability 0.0000 Rb = 0.00 Le = 0.00 Ft Kbe = 0.0 — — Loads Uniform TL: 400 =A Uniform Load A — R1 = 3737 R2 = 3737 SPAN = 18 FT Uniform and partial uniform loads are lbs per lineal ft. Notes NOTE: RIDGE DESIGNED AS STRUCTURAL BEAM TO ELIMINATE REQUIREMENT FOR COLLAR TIES Town of North Andover Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1) BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3) WORKERS COMP AFFIDAVIT 4) PHO"r0 COPY OF H.I.C. AND/OR C.S.L. LICENSES 5) COPY OF CONTRACT 6) FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS / DECKS 1) BUILDING PERMIT APPLICATION 2) FORM U 3) MORTGAGE PLOT PLAN (MINIMUM) 4) DEBRI REMOVAL FORM --5) WORKERS COMP AFFIDAVIT --6)..PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY) 1) BUILDING PERMIT APPLICATION 2) FORM U 3)GROWTH MANAGEMENT BYLAW 4)*CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY,OF H.I.C. AND C.S.L. LICENSES 6) WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to be returned) TO INCLUDE SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the board of appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with application. 0 cud a �V6 v� , _- -- -- ---.,�- rib %I;K3 p�codo�� ,�rrod prva .}a�.r+n, Q M�N +ro�a P N, MSN 09.-g.5-t- /1 V� 0.J r+' 4;J.'A-0 >0 rY-V'°(y ��t�r-�i� tom►W7Z�� 9) + r 4 { r a Town of North Andover4 �OerH O " a , Office of the Health Department �� °' ' Community Development and Services Division # _ 27 Charles Street " � p9 North Andover,Massachusetts 01845 ��Ss HU Sandra Starr Telephone(978)688-9540 Health Director Fax(978)688-9542 April 16,2003 Christopher Murphy 16 Carlton Lane North Andover,MA 01845 Re: Application for an addition to an existing home at 16 Carlton Lane Dear Mr.Murphy: Your application for an addition at 16 Carlton Lane has been reviewed by the Health Department and denied for the following reasons: 1. ✓ Missing information 2. Passing Title 5 inspection of septic system may be required 3. Location of structure not acceptable To address the problem(s): If#1 is checked, please supply: 11 a. Floor plan of the existin elling(all floors)and a floor plan depicting the proposed addition. All rooms m t be accurately named; b. Certified plot plan sh 'ng house,septic system and proposed project in scale,including any associate grading. 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. The proposed the project must meet all current Title 5 setbacks. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincere J.2UGras—se,LHealthpector Cc: Building Department File l BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 FORM U - LOT RELEASE FORM TRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT {p PHONE LOCATION: Assessor's Map Number PARCEL_ SUBDIVISION LOT(S) STREET Car t � L/JN ST. NUMBER ************************************OFFICIAL USE ONLY******* *** * ** ********* REC MENDATIONS TOWN AGENTS: CONSERVATION ADMIN" ATOR DATE APPROVED 1-ps DATE REJECTED COMMENTS 11Ai G.J S qpp rc)(, 102r CUA)gu TroowLj tocA WJ( c ro.A i,40 At i00, bItuer 70at, fwr I6- Q.-btt IN-41 TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED }4 SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS i�0 c. ( PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) Ina DATE OF PUMPING: �3'�� QUANTITY PUMPED / � GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) i SYSTEM PUMPED BY: r���� i i COMMENTS: i CONTENTS TRANSFERRED TO: ', i(W4,•r'✓7l f:f�t Yyl !..' IL 1 1.., 1• ✓�1.1 I _ Y .. TO • WN-OF NORTH .ANDOVER SYSTEM PUMPING RECORD �� ,� �y,��'�[��a��'r+,�i #x.11 1i 7 7. �I VY.s •�r},l 1, I • ytI r3 h Yr y I I+ D ,IrA :..., I yI tii ..,y I,. '^�Yr.,� i l•,.44!d+�, }..3� tl`I''I�ifit I 1f}1ff+zf }r T•`�Ai y, I.+r' }#5+ k til 'h , }jnlr tl 53 S + ;�'.�"t�Sc,•� 8 d}r�f t}�nlS'�'. j �s 1- - t , .� .. ... SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example: left front of house) � nA Ylt "y4s }jil rlsral ij' $-�1 � j T a 4 vs c-. 4�, '7} '��°�� '��f� �' �'riMk'`�'(i�f 4'��'*n1+e�,j4l; 4�rrr' .'„�7"xHH" .� 'r s S �, �•r ,..a,�;.� �, ,�, .._. , .z. t 4 { � �kP` , r t*; i ATE:OF PIPING: �/"1 -� I U Q ANTITY PUMPED d ark GALLONS ( x �Y' ������t��i�ta�lt}t 4t�",a, (ter , � '• , ,,:.i � { '�a SII ' a'��''1ESSP•,OOL:=NO-. .... YES SEPTIC TANK: NO YES �Y\ � t � r Ih C'I r i +,�i.,r'_tiq a, ay I .. •. i � ifye �' 1,�"•a �4 � 414: ,r.: NATURE OF SERVICE;` I E. ROUTINE, X-,-- EMERGENCY �,�19Y+� , ���,fni!''}.C�'(��fll�1�y}p x�f�{"�I;,�II {f . •1 y n .. ..,. .. � - c f.�{�+ �+a X441.; '7S ��4 ,,..' 511 .,-.� , , �••A " �! .' �t> a N>,I`" "tClS,NATION$: . TI COND ION' FULL TO COVER 'j( : HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED { 1 SOLIDS CARRYOVER OTHER(EXPLAIN) I '4,Is !fl,1'• 1I; PUMPED JIY- - �•1,+p 1J jf LP4{fl�.+'�j"�r 1, 4V 'i w F`w 1 tF �Y I 9, std,t !�'a',�l�r V. v. v vs G- Q"�MIM�N • , t f r r� fir•+. � r :`I` y Ir. i , ttl ` t [ S'TRACY FE t z t � �`..�!"'r��� �}�jh J't��k� FSI ��'�^+tl� I.y It y, tl..F, �r•,� 'Y� + �'Vs�;�' ,^;"' r / ,, '� y L P� a i � tL, I t t �i�r I 4e, I ,•,tSr t t�, � V.Sz"�.-.-� i, !'r'. i , +nI zt ✓rk jl t7'�tta SI �(j, s f •'11 !r//Y)/�/ti ///�.!/'U.. 4 , MAY a , •,!. F,. Gid: a s r' em i yd r + ..' 42001 p• u. t 3 /C�'�t G•f rl �;11 4 r(. , f`' ��r{t , �I.,,' •t l � �� Address AP..C-4 Q f.T'o/�,< 1,A( Title of He Page of Date File Open: Date file closed: C►oc Document/Action Title action Date of 62efer to other Purpose of Document/Action and notes Document/ document/ Num. Document/ Department Board of Appeals — Board of Health-- Plan niin.g.board - Conservation Comm' — — �ssian B�ildin� Departrmen�t �j G' FORK! U - LOT RELEASE FORM INS T RUC T ICN.: . 7-nis form is used to verity that all necessary approvals/permits from- Boards and Departments having jurisdiction have been obtained. This rices not relieve the applicant andlor landowner from compliance with any applicable or requirements. AFFLICANT FILLS CUT Ti-i1S APPLICANT SPSSP sficnl,`ey� FFCNE (003�l(—y3�1 LCCATICN: Asseszces �iiap Numcer 16 74 FAFCS_I SUEDIVISICN LOT (S) STRI=_=T ltby) LY� ST. NUMEER�_ OFFICIAL USE.CNL RECOMMENDA T 1 NS OF TOWN AGENTS: CONE cVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENAok— T.. TOWN PLANNER DATE APPROVE! DATE REJECTED COMMENTS 4FOCINSPE OR LT DATEAPPROVED DATEREJECTED IIVSr OFc-�iE4LTH DATE APPROVED -' j DATE REJECTED COMMENTS a%✓ r PUELIC WORKS -SE-iVERMATER CONNECTIONS ` DRIVEENAY PERMIT FIRE DE=AR7MEcN1T r RECEIVED EY EUILGING 1A1SPECTCR DATE r, If ARI 2 2000 Revised S�9;im IBUILT;NI G DEF� TIMENTi a VER/ TOW 'JOF RT AN OF �p0 Commonwealth of Massachusetts O Executive Office of Environmental Affairs APR 1 7 19% Department of Environmental Protection William F.Weld 4owmor Trudy Coxe Secretary,EDEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: /� 11r6 L114 '-"q°auP/ �� 41 Address of Owner: Date of Inspection: (if different) Name of Inspector: S�tn � U 1 Se� -t Company Name, Address and Telephone Number: pQ1v« �Pp /(c, — frrw avf`S 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 Fails Inspector's Signature: Date: The System Inspector sh II submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need' to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why trot) The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(611)556-1049 a Telephone(611)291 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16 14'A/'o 0 `-'e Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required 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 ` C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: '. 4 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 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 fee! to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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. D] SYSTEM FAILS: Aj 4. I have determined that the system violates one or more of the following failure criteria as defined 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. _ Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 1P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: O-y 1,A1 /~' A-lo U v P&-, Owner: Date of Inspection: D)SYSTEM FAILS (continued)•_ r �� Static I' uid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. ) Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: IN. The following criteria apply to large systems in addition to the criteria above: The design floe, of system is 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: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 s k. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / Owner: UIQ/ Date of Inspection: Check if the following have been done: L,P/umping information was requested of the owner, occupant, and Board of Health. _None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates �uuring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ s built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 'be system does not receive non-sanitary or industrial waste flow^ The site was inspected for signs of breakout. ZAII system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or ties, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or roximated by non-intrusive methods. Zp . —The facility ov, ne; (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 a. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /_ Chile&rG-y G.y }l Owner: (!/ Date of Inspection: a– 9� FLOW CONDITIONS RESIDENTIAL: Design flow: ¢allonsf Number of bedrooms: Li L Number of current residents: Garbage grinder(yes or no):–W(3 Laundry connected to system (ye) or no):� Seasonal use (yes or no):_ V Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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:-4cC(/0 -e OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped fj�'+ gallons Reason for pumping: ♦f ('Gt Pct. NSG C4 TYPE Of EM 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: /y Sewage odors detected when arriving at the site: (yes or no) A (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l �J SYSTEM INFO (continued) ION Property Address: Owner: Date of Inspection: SEPTIC TANK:_�(g (locate on site plan) Depth below grade: 9� r� Material of construction: _t�Foncrete _metal _FRP—other(explain) Dimensions: ' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) f=ff=Gr � � d /� 07/T/V X 6 o 10 GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sci,m to bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 s 'r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��v/�OH G� �/ a V Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ . (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:VQS (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributicr i, equa!, evidence of solids carryover, evidence of leakage into or out of box, etc.) 501t GoGO CIO/JQ/ 1100 Nv .71<M 0-4 Csvey nuP✓ PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /6 C71,,A& l eJ4 // A41 Do v ed 04 Owner: 114 C U/N C.. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):--�,r to S (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ /y (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: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) $ r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 11,&4SYSTEM INFORMATION (continued) Property Address: //� (. r�� G� �� 'r 00 U Owner: f 14 C 6,,o ht Date of Inspection: A-/- ;;t-- SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 1 / 7.11 I 4,A DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: (revised 8/15/95) 9 APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. wz hereby make application for a permit for a sewage disposal installation at I will install this system in ac- cordance with all the la4b of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of -z lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE 10 I,F' Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE /a - / 7/ Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as describe . DATE /b �. 7 1_ f Signature of gnskecting Officer -4 Percolation Test 667 Garbage Grinder / BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. df �h ti ?D - 16 L 1. NAME r�^1 `� 4 C_ DATE ✓ 2. ADDRESS LO1 0. TEL. 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER) MASSACHUSETTS SEWAGE DISPOSAL DATE NAME OF APPLICANT__Curtis e ei n man:t roj=- LOCATION Lai-, #19 Raleigh Tnirarn Address of Lot no. BUILDING: Dwelling Other SYSTEM: New x Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clays Gravel Sand PERCOLATION TEST g minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1_O00 gallon capacity, LEACH FIELD 200 lineal feet of drain pipes 11611'r gravel under bed illiam J. D i coli, Engineer Board of Hea t ,���I�, � l ���t•�1�rt�1�111 �,t �' x, • f 1 } chusetts OVER MASSA Hl ° S-tfi u� �. `Set'Pumpin�'Record '6 ,Rx iii# Ft,0�111 41` �t �Yf�r1>rl >ar�, JUL O 5 gra. K' ' r r�IFi;�4 ri flK.i'1tr��F1torr( 7 290 DEP..hai provided this form for use by local Boards of Health. T TOWN te�NJRT``A'`''-', " be submitted to the local Board of Health or other approving author ty, rnping Record must �._ A Facility Information �f,,,Wt►en funs out 1 ' . System Location ��nuter ..only the tab.key Address to move your cursor•do not CI /Town . use the return tY State p Code System Owner,', ; Name' ;r, Address(if different from location) Clty/Town'.. State C Telephone Number Y�6. Pumping Rekord ,('.! r•� 1 .' Data of Pumping ' Date 2. Quantity Pumped: l ' Gallons TYPO of system ❑ Cesspool(s) R Septic Tank ❑ Tight Tank 9 - :❑'�Other(describe); Effluent Tea Filter present?.❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No '; , ,,r r 5 ;Condition of System;' .. ... .. s ti .7 VI i11 1.t '• 1,r Iry La's If(/• ( '�'!�_ . rI .IIrJ � I r'S �•..sy eft Pumped By;; • :' tib. ;. •;,..:: � .. j Vehicle ice Number tr 1'4t h FM 1,/ f������ f ����f iri I .•, \I r r�Vl /• W{ . �'Sr• Yt.. �t tT�.�I�r y�rt, ,4`f I�kJ Ilk •'t �.� // .. ',�y r ' �� „,�omP+{�Y,?a'��;ybt';ir,�ff�,�,lG,�vrlc :�•,� i , � , J `y rr, ,,•�•J✓Yr1Y11�JV•tyW� rrr.�11'rry4,lYl+.4'•�� 1 7 Location wherecdontents Were dl;3posed: .� •1rJ1 v-.J, P� r:�, rbc. ,� . ' I! 1� r.�� /J Signature 01 XIIN3 Date httpJ/www.mass,gowoep.Witer/approvals/t5forms,htm#Inspect t5fomv{.doc'08103 ' System Pumping Record Page 1 of i Commonwealth of MassachusettsE RI�CE1'V�D Ci ty/Town of NORTH ANDOVER MASSA HUSETTS System Pumping Record CBCT K- b T010 y` Form 4 TOWN OF NORTH ANDOVER TH DEP has provided this form for use by local Boards of Health. T EpARTMENTord must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms the cctrle-4c-� computer,use only the tab key Address to move your 0— cursor-do not L/ use the return City/To n Sta a Zip Code key. 2. System Owner: Name Address(if different from location) City/town State Zip Code Telephone Number B. Pumping Record AV 1. Date of Pumping 2. Quantity Pum Date � ped: Gallons 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: aw 6. System Pum ed By: re rn eVehicle License Number 7. Location re contents were disposed: osed: at�r§of r Date http://www.m ss.gov/deptwater/approvalstt5forms.htm#inspect t5fonn4.doc-06/03 System Pumping Record•Page 1 of 1 t i COMMONWEALTH OF MASSACHUSETTS i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r w �f TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTA4Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEIIFORM PART A CERTIFICATION Property Address-& L of L� Owner's Name: rim,r /_T_1 Owner's Address: Date of Inspection: Name of Inspector: (please print) cel-j2 d Company Name: 4 r ,S'PQ/'"�G Mailing Address: ��►�' 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: asses Conditionally Passes Needs Furthe Evalua ion by the Local Approving Authority Fails Inspector's Signature: v ate: The system inspector shall/s, mit a copy of this inspection report to Approving Authority(Board of Health or DEP)within 30 days of co pleting 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 6Cb�011 OF NORTH ****This report only describes conditions at the time of inspection and under th &3ibq eAlkit time.This inspection does not address how the system will perform in the futur4undW the same or dr'Rerent conditions of use. WAR 2 O , 1 i Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Ca/- of GAld ,4 /2 ,2. Owner: 3?" Date of Inspection: Q Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Systeses, have not found any information which indicates that any of the failure criteria described in 310 CMR 15. 03 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Y 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ._; . .Observation of sewage backup or.break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner• C' L vST Date of Inspection: '- C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. .•I.—.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 ofganic 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 J' Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:/b Owner: ,�f v4rGS 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 grounor or surface'waters'due to an overloaded or ;ed SAS or cesspool tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or — !f cesspool utd depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped y 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 grater supply. 0y portion of a cesspool or privy is within a Zone 1 of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 compoaeds 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each.of the following: (The following criteria apply to large systems in addition to the criteria above) 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 l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6/z nod ' Owner: USr' Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes ' o y h P raping information wa" ided by the owner occupant,or Board of Health --W - , �• 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? ave 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? V! 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 s maintenance of subsurface sewage dispogal systems? ' , Tht-size and!locatiob..bf the Soil Absorption System(SAS)on-the site has been determined based on: X-0 Existing information.For example,a plan at the Board of Health. { j/_ 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION Property Address: / n Et Al Owner: Date of Inspection: -S d FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): �/ Number of bedrooms(actual): DESIGN flow based on 310 CD9, 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: A Does residence have a garbage grinder(yes or no)N ».. ..Is laundry on a`separate sewage.sy m 6166 or no): {if ye"s separ`atetinspection'required] _ ._....- Laundry system inspected(yor no):_ Seasonal use: (yes or no):4 Water meter readings, if av liable(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: t V -e COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records -/ Source of information: `')�Gt r S ¢�G�✓(.�C�. ��T-1 (,,, Was system pumped as part of thVinspection(yes or no):y CS` _ If yes,volume pumped: 0gallons--How was quant,ty pumped de ermine/ � Reason for pumping: / t-' .• ` n� a/�, TYP F 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): 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):�-=G1 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:/b 8 � Owner: Date of Inspection: f' BUILDING SEWER(locate on site plan) Depth below grade: 33 Materials of construction: WaTiron _40 PVC_other(explain): Distance from private water supply well or suction line: ; ti. Comments(on,cgndition of joints;vgntinik,evidence of leakage,etc.) * ` SEPTIC TANK:Z(Iocate on siteP lan) Depth below grade Material of construction: ncrete_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: 5 )C S r S X Sludge depth: Distance from top of edge 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 bottomof outlet tee or baffle: How were dimensions determined: v Comments(on pumping recommendatio ,inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate to outlet invert,evidence of lealyage,etc. DO .+� GREASE TkAP:_'(Iocafe,ori site plan)- Depth ian)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 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L A.� dG�C Owner: 64-1. 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: 1*05(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:&ot7/h-U Comments(note if box is level and distribution to outlets equaL,�'any evidence of solids carryover,any evidence of leakage i o or out of box,et .): o O�. NO l!d L C— AO i r PUMP CHAMBE (locate on site plan) Pumps in working order(yes or no): ;+ Al", s'in worliing orde?(yes band): k. . Comments(note condition of pu(np chamber,condition of pumps and appurtenances,etc.): 8 "* Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .Qr L' 'Q 2 Owner: KCq 47— Date Date of Inspection: d 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: d leaching trenches,number,length: L4'N 9 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.): Q o m GY % da Soy 14- rz 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: t Depth of scum layer: f Dimensions of cesspool: Materials of construction: Indication of groundwatgr inflow(yes or np): .. y i , Com' ents(note condiffon of s 1,signs f hydraulic failtire, level of pond`fng,condition of�v6getation,etc.): e r PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address:14 6 /'L' nl V4 x/ au--e Owner: Vxor4 r ?-�- Date of Inspection: 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 withi410p fe't.Locate where public water supply enters the building. � i o - a z k y �t t s Y 17F U 1 10 Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A, , 4-1-L © i C 1 . e n A1r Owner: Q ' �]"" 17e US Date of Inspection: SITE EXAM Slope Surface water r. Check cellar Shallqw wells Estimated depth to ground water feet " Please indicate(check)all methods used to determine the high ground water elevation: yt7'rtained 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: d/thecked.with local excavators, installers-(attach documentation) Accessed USGS database-explain: You ust des ib�how you es blished the high round water elevation: i7 f4— a t4.4 k j� 11 Commonwealth of Massachusetts City/Town of No andover System Pumping Record Form 4 `M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab do � \ key to move your Address cursor-do not No Andover Ma use the return --- — key. City/Town - -- - -State Zip Code 4:1 2. System Owner: RECEIVED A0 L'lk�ig(j Name I JUN return 2 Address(if different from location) TOWN OF NORTH ANDOVER City/Town State AR d Telephone Number B. Pumping Record �/ 1. Date of Pumping / 2. Quantity Pumped: C Gallons 3. Type of system: ( rCesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes EAo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:�� 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-tregftent Plant, 20 So. Mill Bradford, Ma 01835 Signature of Har Date Signature of Re eiv' g Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1