HomeMy WebLinkAboutMiscellaneous - 161 RALEIGH TAVERN LANE 4/30/2018 (2) 161 RALEIGH TAVERN LANE Lane
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AS BUILT PLAN
OF
sUBSURFACE DISPOSAL. SYSTEM
LOCATED IN
000-To AJ Dov'E; R- , ►� o tic ,
AS PREPARED FOR
DATE: IZ-3 •`�4
SCALE: I ''= y D'
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER. MASSACHUSETTS 01810 or TEL (617) 475-3553. 373-3721
Commonwealth of Massachusettsc b�
JO V,
Executive Office of Environmental.Affairs
Department of ppb.
Environmental Protecto-n
William F.Weld Trudy Coxe
Governor
secteWy
Argeo Paul Celluccl David S. Struhs
U.Governor
Commruaner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ,
Property Address: A, I I e i y /R,./,P-(-A/ Address of Owner. .
Date of Inspection: 7� �}�—q(o / (If different).,
Name of Inspector. // OGS �R i e Sci�✓
Company Name,Address and Telephone Number. BATESON.ENTERPRISES; I NC. TEL:ts08)175_11-;
Excavating-Water 3 sewer Lines-Septic Systems 6 Pumping Service FAX:15.08)1 5-5151
I I 1 Argilla Road a Andover,Mass.01810
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,
�aiLs
Inspector's Signature: Date:
The System Inspector shall 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: µ
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"i explain why not)
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 Fonforming septic tank as approved
by the Board of Health.
(revised 11/03/95)
One Winter Street a Boston, Massachusetts 02108 et FAX(617)556-1049 a Telephone(617)292-5500
Pnmed on Recycled Pape.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t_
PART A ,.
CERTIFICATION (continued)
Property Address: �(,� 2i ci Tad¢rtiJ .Liv, lq~epd✓.e fZ
Owner. « .
Date of Inspection: �S ����� Qf Alen✓
B1 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 f(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 1. The system.will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced +
obstruction is removed
Cl FURTHER EVALUATION 19 REQUIRED BY THE BOARD OF HEALTH: ,,-
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 feet to a surface water supply or tributary to a
surface water supply. r
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.
3) OTHER
(revised 11/03/95)
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �G P R Q Y h Ti�J tftiJ .4 . Oil"
Owner.
Date of Inspection:
D1 SYSTEM FAILS:
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 componeAt due to an overloaded or clogged 8A3 or oeue 1.
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 Is than 1/2 day flow. Yq ;
Required pumping more than 4 times in the last,year NOT due to clogged or obstructed pipe(s). z
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&6,t..o' 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 ham 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: "
The following criteria apply to large syatems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 H 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 officeof the Department for further information.,
(revised 11/03/95) 3 .�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST w
nn zt .
Property Adaresa /�p I UD R ' e y l�4 v R .� 1 ave e I,,-
Owner.
ZOwner. I'1��
Date of Inspection:
Check if the fool/llowing have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
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.
L''The system does not receive non sanitary or industrial waste flow
_The site was inspected for signs of breakout.
L—"AIl system components, excluding the Soil Absorption System,,have been located on the site.,,
G"The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods. ;{
"e facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:_64/1 gallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yea or no): Je
S
Laundry connected to system(yes or no):—)D
Seasonal use(yes or no):_ALe
Water meter readings, if available: !�
Last date of occupancy: i& -lf
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_ "
Non•sanitwV waste discharged to the Title 5 system: (yea or no)
Water meter readings, if available:
Last date of occupancy:
OTHER.,(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
19 9 ( •w,� �cZ� . . . .
System pumped as part of inspection: (yes or no)�6o
If yes, volume pumped: /c e o gallons 7—
Reason for pumping: CA-iLk 51t�4urjL r-ZA—k 'k Co :d11S a F, 814 F/QS
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)
Other(explain)
APPROXIMATE AGE of all components, date installed(if known)and source of information: I q ? I (O L"
Sewage odors detected when arriving at the site: (yea or no)
(revised 11/03/95) 5 a ;.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 1NFORM.ATION (Continued)
Property Address I AOef nJ L N
Owner. 0ti1 tS . 1 r..d Q t w�✓
Date of Inspection:
SEPTIC TAN13s1,-,—
(locate on site plan)
Depth below grade: Z� All Li,•>rs
*Vrfid;l Of e$t strraetien; ncrete;metal_FRP_other(explain)
Dimensions: y X y x H X '7, S
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 6 �
Distance from bottom of scum to bottom of outlet tee or baffle: /9
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.) -S <<-T .,k I Z it F:Fbe s Ac-e-:e& _, Mends oiJ Li Tae,
pp I / .. L
-. U f= lg-k-toz : 9�t p-e )7r"— Pin( Ards► Qa't�.1.�aQ --,r-r,4rs l��.0 A we0..."0
GREASE TRAP: s/e vO
(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 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.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addreae- �R Qi' -7 4✓4.lrA/ ` ,L�v • �iw• /9�.�[d✓e 2
Owner. /11r'S 1 -c��a Q3�q✓r✓
Date of Inspection:
3 - C3�- 9�
TIGHT OR HOLDING TANK A VlvX
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP—other(explain)
Dimensions:
Capacity: ¢allons
Design flow: gallons;day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches,'etc.) '
DISTRIBUTION BOX-
(locate
OX(locate on site plan)
3 r
Depth of liquid level above outlet invert:��� n
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Ql- SLK
p� V
l liS r brw. iosJ
'.5 epf he'gvi el'jt e'grrvou.iR /Vv as .a%k i;t pr
�
PUMP CHAMBER: Ween
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7 ,: '
n i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address ��I Q���.�y h TAv2 r..J �'�/•
Owner. !4!
Date of Inspection:
3-tea-9�
SOIL ABSORPTION SYSTEM (SAS): '
(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: U
leaching trenches, number,length: . eu-5
leaching fields, number, dimensions:
overflow cesspool, number: CC ` 1
Comments: (note condition of soil, aigns of draulic fail level of ponding, condition of vegetation,etc.) .JO t• y�?@.147rC1tiJ
, Q- B a w ar w b .s_ r— c ✓a}� ,e s /�
o (L o
-7;,p d F
CESSPOOLS: NrNF_
(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:
Mow(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 11/03/95) 8 `
4 ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: JRpd 2 �y h I r�✓xr ��,, f�o • ✓Lo I
Owner. S �; .��.� Q( awe✓
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
3 � 3
� -3
13 '-3
J`
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation: 3 'S f T Q Ic Tt Kc(.2S No wq 7e(Z
IrR11.)S,'T oto✓A7urJ o1= �du _. �O � o . �i2r.c�c5
(revised 11/03/95) g `~
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
CURRENT INSTALLER'S LICENSE#
DATE: zz�����
LOCATION:
LICENSED INSTALLER:
SIGNATURE: TELEPHONE#
CHECK ONE:
REPAIR: ✓' NEW CONSTRUCTION:
l F NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Adm nistrative Use Only
$75.00 Fee Attached? Yes No
Foundation_ As-Built? --Yew�s-- No
Approval Date:
J
i
Form No.4
Town of North Andover, Massachusetts
BOARD OF HEALTH
February 28 r19 97
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (X)
by INSTALLER
at SIT LOCATI
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No.
840 dated 4/24/96 1g
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
1- BOARD OFHEA TH
Form No.3
Town of North Andover, Massachusetts
BOARD OF HEALTH
HORT1y
9 Q le
A
41
F 9
•e4a
�,�-�,,,,;.•�� DISPOSAL WORKS CONSTRUCTION PERMIT
• SSACMUSE
Applicant DDRE55 TELEPHONE
NAME
Site Location 1 In
Permission is hereby granted to Construct ( ) or Repair (/ Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN,BOARD OF HEALTH
Fee D.W.C. No.
s
i
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS..
p ae44 /,4de-
1. NAME C� S /f'k Go �'7r DATE
2. ADDRESSJ-04 LOOT NO. ' � TEL. ����J ✓r�
3. NO. OF BEDROOMS DEN YES- X NO
4. GARBAGE GRINDER YES N0_K,__
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.
A
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make applicatio . for a permit for a sewage disposal installation at
3 _71--l-11111 . I will install this system in ac-
cordance with al _ the laws 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 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
ignature of Applic
I hereby issue the above permit for t e Board /ofHealth of the Town of North
Andover, Massachusetts.
DATE
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE /O /7/
ti
Signature o nspecting Officer
Percolation Test
Garbage Grinder
BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS
SEWAGE DISPOSAL
DATE 8/22/7 n
NAME OF APPLICANT John J. Burke
LOCATION Lot #23 Raleigh Tavern Lane
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X' Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay__2L, _ Gravel Sand
PERCOLATION TEST 8 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1.,000 gallon capacity.
LEACH FIELD 2`00 lineal feet of drain pipe.
William J. D scoll, Enginee
Board of Heallh
: Town of North Andover, Massachusetts F°""No.s
„°RTh BOARD OF HEALTH
Mel" a4 qx
P
DESIGN APPROVAL FOR
,SSACHUSES� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Z /./)lo -5,el�L(Jl-) Test No.
Site Location_. ��
• Reference Plans and Specs.
ENGINEER DESIGN DATE
: Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
: Fee '"� Site System Permit No. f
• F
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PLAN REVIEW CHECKLIST
ADDRESS /W// ����/G/y T,411600-ENGINEER - 'Z)[) f.eE5A-J6
GENERAL /
3 COPIESy STAMP LOCUS NORTH ARROW �! SCALE
CONTOURS ' PROFILEy! SECTION 1/ BENCHMARK cam,,..._.. SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS
WATERSHED? DRIVEWAY (Elev) WATER LINE 6--" FDN DRAIN
SCH40 TESTS CURRENT? `� SOIL EVAL
SEPTIC TANK
i
MIN 150OG . 17 INVERT DROP GARB. GRINDER /V �(+200o EDF)
25 ' TO CELLAR MANHOLE ELEV GW # COMPS.
D-BOX
SIZE # LINES FIRST 2 ' LEVEL STATEMENT
INLET 9 , OZ - OUTLET %b` - 17 (211 OR .17 FT) TEE REQ'D? /00
LEACHING
MIN-4646—GPD? r RESERVE AREA 4 ' FROM PRIMARY? 2% SLOPE
100 ' TO WETLANDS '---� 100' TO WELLS `--� 4 ' TO S.H.GW '�f (5 ' >2M/IN)
35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP
4 ' PERM. SOIL BELOW FACILITY MIN 12" COVERy/FILL? (25 '
if above natural elev; 10 ' if below) BREAKOUT MET?
TRENCHES
MIN--6fr6 gpd r/ SLOPE (min .005 or 6"/100 ' ) L' SIDEWALL DIST. 3X EFF.
W OR D (MIN 61 ) �l RESERVE BETWEEN TRENCHES? '-- IN FILL? UST
BE 10 ' MIN.-.>e�L411 PEA STONE?L,-' VENT? (>3 ' COVER; LINES >501 )
BOT 44 + SIDE � / � X LDNG TOT
(L x W x #) (DxLx2x#) (G/ft2)
RJOTE .` G G o2 �vu0 U&16
Copyright 0 1995 by S.L. Starr