HomeMy WebLinkAboutMiscellaneous - 163 LACONIA CIRCLE 4/30/2018 •ci _ p -
163 LACONIA CIRCLE e
210/1-05.D D132-0000.0
t t Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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 j
filling out forms 1+
on the computer, RECEIVED
use only the tab 1. Inspector:
key to move your
cursor-do not John J. Soucy SEP 12 2016
use the return Name of Inspector
key. TOWN OF NORTH ANDOVER
Soucy's Sewer Service Inc. HEALTH DEPARTMENT
rad Company Name
78 North Broadway
Company Address
,eSalem NH 03079
City/Town State Zip Code
603-898-9339 13397
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
❑ eds F rther Evaluation by the Local Approving Authority
Z7 oj-a ly- f—\oaA 08/29/16
nspe Igna re Date
T e system inspector shall sub it a copy of this inspection report to the Approving Authority (Board
o 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•3113
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 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
t
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
163 LACONIA CIRCLE
Property Address
f
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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 'h day flow
t5ins•3/13 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 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
page. Cityrrown 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-
j 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•3113 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
163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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 an of the system components pumped out in the revio
❑ ® y y p p p 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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
x 'i - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
I
I
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
SEE ATTACHED
Sump pump. F1 Yes ® No
Last date of occupancy: CURRENTDate
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENT
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Soucy's Sewer Service Inc
Was system pumped as part of the inspection? ® Yes ❑ No
1500If yes, volume pumped:
gallons
How was quantity pumped determined? Gauge on truck & Plans
Reason for pumping: Maintenance and Inspection
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
�M 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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:
7/08/1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"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.):
NO APPARENT LEAKAGE
Septic Tank(locate on site plan):
8"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
II
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
6'X 10.5'
Sludge depth:
3"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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
39"
Scum thickness
4"
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 AND SLUDGE TOOL
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK IS STRUCTURALLY SOUND. NO APPARENT LEAKS. TEES IN PLACE.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M , 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
page. Cityrrown 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.):
"D" BOX REPLACED PRIOR TO INSPECTION. SEE PERM IYT/COMPLIANCE.
INSTALLED"D" BOX EXTENSION TO GRADE.
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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: ( 2 ) 41'X6'
❑ 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 SIGNS OF HYDRAULIC FAILURE
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owners Name
information is
required for every N. ANDOVER MA 01845 08/29/16
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.):
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is N. ANDOVER MA 01845 08/29/16
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
--------- -
v
F"
V ? 357
�� 00
03 r
z ,
8-V
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
page. Cityrrown 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: T
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: 1987
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
NO WATER 12" BELOW BOTTOM bF"D" BOX. BOX BOTTOM 5' BELOW GRADE.
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M a' 163 LACONIA CIRCLE
Property Address
PAMELA DAVIS
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 08/29/16
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, 6, 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
I
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 P Y g 17 of 17
—._._..... . _.._._....._
I
_. . _.. _.._.._... . .. . ......_. . ... _.
Commonwealth of Massachusetts Map-Block-,Lot
t 105.D0132
I
' BOARD OF HEALTH PennitNo
North Andover BHP-2016-0255-------
PI tr>
Ri. $175.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted JOhn SOUC
to(Repair)an Individual Sewage.Disposal System.
at No 163 LA.CONIA.CIRCLE
as shown on the application for Disposal Works Construction Permit No. BHP-2016-025 ust 16,2016
.ir
...
Issued On:Aug-16-2016 BOARD OF 1-1EALT:.
I
•..S�gTLEW .
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community and Economic Development Division
CERTIFICATE OF.
COMPLIANCE
As of: 9/1/16
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D-Box
By: John Soucy
At:
163 Laconia Circle
Map 105.D Lot 0132
N rth Andover MA 01845
Thq Issuance of this cert' is be construed as a guarantee that the system will function satisfactorily.
9
Michele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
� 5�T5L'EDl6g6' .
•
North Andover Health Department
Community and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 163 Laconi Circle MAP: 105.D LOT: 0132
INSTALLER: John Soucy
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
D-Box INSPECTION.-
DATE
NSPECTION:DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
Installed on stable stone base
H-20 D-Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
i
❑ Speed levelers provided (not required)
Schedule 40 PVC Pipe
46 `�
Comments.
U" 1
- IL ---._.._
-----_-__-- _ BOARD OF HEALTH
•, wTni� . Commonwealth of Massachusetts
Map-Block-Lot
105.D0132
• BOARD OF HEALTH PermrtNo
North Andover BHP-2016-0255
-----------------------
FEE
$175.00
------------ ----------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John-Soucy - -to(Repair)an Individual Sewage Disposal System.
at No 163 LACONIA CIRCLE
-------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2016-025 Dated August 16,2016
------------------------------
----------
----------------------------
---------- = _ PY
Issued On:Aug-16-2016 BOA OF HEALTH
Application for Septic Disposal System
;< s
Construction Permit - TOWN OF TODAY'S DATE
-Full Repair
NORTH ANDOVER MA 01845 $175.0 -Component
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system*
forms on the
computer, use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key Repair or replace an existing system component-What? "D" Box -
to move your
cursor-do not
use the return A. Facility Information
key. 163 LACONIA CIRCLE
ua
Address or Lot#
N. ANDOVER RECEIVED
City/Town
2.- *TYPE OF SE IC SYSTEM*: AUG 16 2016
➢ ❑ Pump ElGravity(choose one)
***If pumps tem, attach copy of electrical permit to application*** TOWN OF NORTH ANDOVER
➢ [ Conventional System (pipe and stone system) HF Ty APARTMENT
➢
El Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to in al is ype of syystem
➢ ElPressure Distribution S.A.S. (No D-Box)➢ E] Pressure Dosed (D-Box Present)S.A.S. /➢ E] Does the system require an effluent filter? Yes No /
40040
if yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? What is the Model.
2. Owner Information
PAMELA DAVIS _
Name
Address(if different from above)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
JOHN SOUCY SOUCY SEWER SERVICE INC
Name Name of Company
78 N. BROADWAY
Address
SALEM NH 03079
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer I formation
A/
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
. Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
VE NORTH ANDOVER, MA 01845 $350.00 -Fun Repair
$175.00 -Component
PAGE 2OF2
A. Facility Information continued...,
5. Type of Building: ®Residential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environment Code, as well as the Local Subsurface Disposal Regulations for the Town of
North An e . I understand that until a final Certificate of Compliance has been issued by
this Bo d of ealth, the ' talled system is not approved.
N Date
A I ion p ed By: (Board of Health Representative)
7a Date
pp i ation Disapproved for the following reasons:
For Office Use Only:
Z Fee Attached. Yes No
2. Project Manager Obligation Fo ttached.? Yes No
3. Pump System? If so,Attach co of Elect I Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviem ed approval letter, all paperwork received. Yes No
Missing.•
5. Foundation As-Built. (new construction only): Yes No
(Same scale as approved plan)
G. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
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FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT:
APPLICANT: !`���/' ��///S Phone
LOCATION: Assessor's Map Number /G S_Z Parcel z
Subdivision Lot (s)
✓Street St. Number
Use Only************************
RECOMMENDATIO OF TOWN AGENTS:
' Date Approved v
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Innspectcr-Health Date Rejected
4
&!,2, Date Approved
Septic Inspector-Health Date Rejected
Coiranents X64
Public Works - sewer/water connections
driveway permit
ire Department
Received by Building Inspector Date
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