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Miscellaneous - 1641 SALEM STREET 4/30/2018 (2)
1641 SALEM STREET 210/106.B-0082-0000.0 I in l r - ► Lot & Street 16 -&l 5192 M /`� Map/Parcel g' CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# lQ 7-3 Plan Approval: Date: � /e Approved by: Designer: PI-ea/m/4G �1�U,� Plan Date: Conditions- Water Supply: own Well. Well Permit: __Driller: Well Tests: Chemical Date Approved Bacteria I Date-Approved Bacteria II e-Approved Plumbing.Sign-Off: Wirir�g.Sign-Off Comments: Form"U" Approval: Approval to-Issue: YES NO Date Issued By: _ Conditions: - Final Approval: ..All Permits Paid? �YES� NO Well Construction Approval? ____-Y-ES Septic System Construction Approval? S 7 NO Certification? S NO Other YES NO t' Any Variance Needed? S 1 NO -) /_*r FINAL BOARDPF ALTH APPROVAL: .X® DATE: / APPROVED&: I SEPTIC SYSTEM INSTALLATION { Is the installer licensed? NO Type of Construction: �7 p� New Construction: Certified Plot Plan Review YES NO -Floor Plan Review YES NO - Conditions of Approval from Form U YES NO _Issuance of DWC permit: - -YES NO -.DWG Permit Paid? SS---) NO . --DWC=Permit# ��- Installer: _-._-- - --Begin Inspection:_ YES NO _Excavation Inspection: T- -Needed: -- Passed: - By: -- ..-._Construction Inspection: Needed: IBuilt Ian Satisfactory: : -_ Approval of Backfill: Date: By: ---Final Grading Approval: Date: . ,� By: Final Construction Approval- Date: By: Certificate of Compliance: Approval: Date: a �� Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 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. A. Facility Information 1. System Location: L /Ri h fr , Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Trp Code 2. System Owner. Name Address(d different from location) City/Town State Zip Code Telephone Number B. Pumping Record , [ ✓ 1. Date f P � � o Pumping gate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No; 5. Conditi n qfO\M-6�?-k � 6. System Pumped By.- Neil y:Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: C� S. Lowell Waste Water A. Bz6z-�-O � l�D �7 Sign a 9t HauleV Date t5formCdoc-06103 System Pumping Record•Page 1 of 1 �LN Commonwealth of Massachusetts 9211 City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authorit . A. Facility Information wir-iiIV -- Important: AUG 0 8 2006 When filling out 1. System Location: forms on the computer, use ILo4i TOWN OF NORTH ANDOVER only the tab keyAddresHEALTH DEPP,R to move your cursor-do not ` �� M I'7 to C, use the return City/Town State Zip Code key. 2. System Owner: VQ Name A91' Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping f�SDC) p 9 oat 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) E�,Septic Tank ❑ Tight Tank ❑ 'Other(describe): 4. Effluent Tee Filter present? yes ❑ No If yes, was it cleaned? ]D�-Xes ❑ No 5. Condition of System:. 6. System Pumped By: Name Vehicle License Number t\�S Company 7. Location where contents were disposed: 10-ay---Yik �Q Q�low.1, IA&A—e- � o� Signature of Hauler -7 Date hftp://www.mass.gov/dep/water/approvaIs/t5forms,htm*inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS JD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION �p�M vev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_1641 Salem Street ' TOWN OF NORTH AN©U4ER/ _North Andover_ BOARD OF HE! .� Owner's Name:_Lada Krokhmal Owner's Address:_1641 Salem Street _North Andover,MA 01845_ }l 1 2 5 ' Date of Inspection:6/18/2004 Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number: (978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper fimction 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority is F Inspector's Signature: h-� Date: 6/18/2004_ The system inspector shall submit copyf this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Y � I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_1641 Salem Street _North Andover— Owner:_Krokhmal_ Date of Inspection:_6/18/2004_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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.. 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_1641 Salem Street _North Andover_ Owner:_Krokhmal_ Date of Inspection:_6/18/2004 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 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 sur_face water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance__ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 1\ Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_1641 Salem Street_ _North Andover— Owner:_Krokhmal_ Date of Inspection:_6/18/2004_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: Yes No _No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or —cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is''/z day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (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. Page 5 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_1641 Salem Street _North Andover— Owner:_Krokhmal_ Date of Inspection: -6/18/2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes — Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes_ _ Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ Existing information. _No 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)] Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_1641 Salem Street _North Andover— Owner:_Krokhmal_ Date of Inspection:_6/18/2004_ FLOW CONDITIONS RESIDENTIAL 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_ Number of current residents:_4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings: Yes_ Sump pump(yes or no): No Last date of occupancy:— Current-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):T Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped last year,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping: Inspect tank&tees_ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) �_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:_5 years old,5/7/1999,As built plan_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1641 Salem Street_ _North Andover— Owner:_Krokhmal_ Date of Inspection:_6/18/2004_ BUII.DING SEWER_X_ (locate on site plan) Depth below grade:_1211 _ Materials of construction: _cast iron _X_40 PVC_other Distance from private water supply well or suction line Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast Iron thru wall, 3"PVC in house, no leaks_ SEPTIC TANK: X_(locate on site plan) Depth below grade:_4"_ Material of construction: X concrete_metal—fiberglass—polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth4"_ Distance from top of sludge to bottom of outlet tee or baffle:_23"_ Scum thickness:_5" Distance from top of scum to top of outlet tee or baffle:_8"_ Distance from bottom of scum to bottom of outlet tee or baffle:_16"_ How were dimensions determined:_Difference between tee length&scum&sludge depths_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)_Pumped septic tank.Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of tank leaking out._ GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:— — concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1641 Salem Street North Andover- Owner:_Krokhmal_ Date of Inspection: 6/18/2004_ 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: X (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-bog level& distribution equal.No evidence of leakage out of d-box. Evidence of carryover,pumped d-box to clean._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):— Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1641 Salem Street_ _North Andover— Owner:_Krokhmal_ Date of Inspection:_6/18/2004_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: _ leaching trenches,number,length: X leaching fields,number,dimensions:—1 field 30'x 37'_ overflow cesspool,number: innovative/altemative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil oL Vegetation ok.No sign of ponding to surface._ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (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.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1641 Salem Street_ _North Andover_ Owner:_Krokhmal_ Date of Inspection: 6/18/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Driveway House A Water Meter B 1 Septic Tank 30' 2 D-Bog T A to 1 =4214" A to 2=46'8" 3T A to D-Bog=5115" BtoI=33'2" Bto2=39' B to D-Bog=3618" Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1641 Salem Street _North Andover— Owner:_Krokhmal_ Date of Inspection:_6/18/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3'2"_ Please indicate(check)all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record-If checked,date of design plan reviewed: 4/10999 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: As per design plan_ 1�`ps �'•', +-.�� U ,�{+ pr s- � -. �� _ .. µµµ. .....: :. it , lit Tiil 00 .IMt a , n , CGOyO+V1,;b,w o-@.oGC-za►L1•AWNh+ ii i a f� I ••+NNNNNNNNNNNNNNNNNN n 1 H -� :.m@@@®@@@@IDmt9t9m@m@m n 1 •AWWWwNM W1--h +F+I+mm@mm r I v ,` � � ,i� �. ���"�`� � � W y� i ." 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C ?-c"�1 *' ,'»��R',z'.rdt' ?".�.��'• A -r,' a �- .... :. -., :.2N• .., ..rrai� .i�v � __ __ - "".�c�`e .. 'nmw,�seyk.'�tr. ,,}q,!;"n,�+,iV'^r III ig �!"p�••r.,,.,d�'Z r• .'.•:�.a z�:�.�>t .ao',.i.�A,xe<. -���- .vp,•, ..:�gl �.iy�, < ,�,r'`v<-TIS°'r+�a43t= ?'•tt`^ -,,:,�![•�A->..t.�'j'•-r�. �� ;•�,� ;.; R7tJTF,EY ... .... _4__ ., ,.1 ,a;,_ti•_: ���� .r -�..� 1,x;,••u' ,,'��?` ' w: G, ;� 'a�`". -...t,,,� i�,,;u. :,8_:� �a��'� '�'...>.•�-> •'h,N ar t .1 .i.;, "•Y3".A7 } '. r •'i.,. 7ner" ?".,,.tn.�+s ""—�." f. ,.t�!. - r .3. 7!G:' 1 , Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass,01810 Title 5 Inspection Report Property Address: 1641 Salem Street, North Andover Owner: Krokhmal Date of Inspection: 6/18/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Peil J. Ba eson Bateson Enterprises, Inc. Commonwealth of Massachusetts �o��oQRo of Executive Office of Environmental Affairs Z\ Department of a�� � Environmental Protectio William F.Weld Trudy Coxe Governor Secretary Argeo Paul Ceilucel David S. Struhs Lt.Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /C�E,RTIFF,IC�ATION Property Address �r0� .� � � . ` "'�"�-x—CJC.7f?.� Address of Owner. Date of Inspection: 1p�one (If different) Name of Inspector. Spy\ Company Name,Address andel TNumber. BATESON ENTERPRISES, INC. TEL:(508)475-14'4 SOB r- ! f� r L4� L?G Excavating-Water&Sewer Lines•Septic systems$Pumping Service FAX:(508)475-5451 «�.J �,J CERTIFICATION STATEMENT 111 Argilla Road a Andover,Mass.01810 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 sal systems. The system: _ Passes _ Conditionally Passes -_ Needs Further Evaluation By the Local Approving Authority _ Fails t Inspector's Signature: The System Inspector shall su 4tcof 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.r 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: r. r A) SYSTEM 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 yea, no,or not determined(Y, N, or ND). Describe b--ts of determination in all instances. If"not determined", 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 conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 '' One Winter Street a Boston,Massachusetts 02108 eFAX(617)556-1049 a Telephone(617)292-5500 �A1 Pnnied on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' < PART A CERTIFICATION (continued) . iPtrop*rty Address: r. ^�- �'�., Owne Date of Insptectiom Bl SYSTEM CONDITIONALLY PASSES (continued) f: q 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(a)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(a). The system will pass inspection if(with approval of the Board of Health): " $•`' broken pipe(s)are replaced, } obstruction is removed t `,• _" . Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: .,a t,; , 4 c ;• 1 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. r 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. + *) t r 2) •`SYSTEM WILL.FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)• DETERMINES THAT THE SYSTEM IS FUNCTIONING INA 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 •,t rt< t""*, =g f"( 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.#.,&e 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 indicater'thatthe'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 I 1.j'€"(' .. (revised 11/03/95) b '. Z .,,rF . �tP' r','- i:a t:t•'r 21r �tf fi.. ., nJ� � - - t f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) .Property Address: Owner. Date of Inspection:8^h ; DI SYSTEM FAILS: r 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 oftspool. 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;V 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 anti 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. 3 �' 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 60 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: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: _„ 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(MPA)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 office of the Department for further information:,. (revised 11/03/95) 3 ,*, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST: Property Address: L( Owner. Date of Inspection: f-7-q6 Check if the folio ' have been done: V _?umpinformation was requested of the owner, occupant, and Board sf.Health. �6-14one 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. . MIA-As built plans have been obtained and examined. Note if they are not available with N/A. VThe facility,or dwelling was inspected for signs of sewage back-up.3 v'The system does not receive non-sanitary or industrial waste flow r sitao.wsa inspected for signs of breakout f I system components, excluding the Soil Absorption System,have been located on the site. 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 facilit-v owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. 4, ' .. . . .. � f '3 - S• �.;f'r,f ,� r �` rpt 't=. .�.=A (revised 11/03/95) 9 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14( Owner. �, -{-Ovl� � ��5 -tt F '# } Date of Inspection: 0 FLOW CONDITIONS ° { RESIDENTIAL- Design flow:_y Y�ll na , Number of bedrooms: ,•s Number of current residents: , Garbage grinder(yes or no): t isundry connected to system (yes or no): V495 _r Seasonal use(yes or no):�D Water meter readings, if available: t Last date of occupancy: — COMMERCIAL/INDUSTRIAL-Type of establishment: Design flow:_.gallona/day y Grease trap present: (yes or ao)_ s a r 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: Inst date of occupancy: r OTHER(Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: -, System pumped as part of inspection: (yes or no) VeN If yes, volume pumped: � �—w ons Reason for pumping:u8� nS^ c� n.t1I n'•1_� �w;,��,.l6,. , S � V� TYPE�YSTEM - Septic UuWdistribution 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 o a fall components, — da to install Po ed(it known and source o f information: CC7 rmation: Q � ev�1P-f" NJ Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 r• D . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I (b y 1 sck�� SA- Owner. A Owner. FAv-. �\S Date of Inspection: p/_ SEPTIC TANK: , (locate on site plan) Depth below grade: +�l Material of construction: lila,rete metal_FRP_other(explain) Dimensions: to -X7 S = 5� ;q OKS Sludge depth: Vit Distance from top sludge to bottom of outlet Lee or baffle: tf 4 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 pumpin v ndition of' et and outletteesor es, d th fp liquid leve L� tion to let my structural in ty, evidence of leakage, etc.) `t�L l� v� Ylv f ucd tuo GREASE TRAP-_tjov ,e (locate on site plan) bra Depth below de: _ P 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.) ' .. ., . . . f•. .a i.,.-ate t .. s (revised 11/03/95) 6 D , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: (o L So,k- 'L. S. --" /v• Owner. f - --rMA-, DaA,,�S r �.a,:•,,> Date of Inspection: TIGHT OR HOLDING TANKV\Ohe- (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: Gallons " Design flow: ¢allons/day Alarm level ; Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: "c .,. Comments: 'r3n`•,,- (n to if 1 veli d distribution is equal, evidence of soli carryover, evidence of leakage into or out of box, etc.) � � e u f 6 C'vcr o� 2 a p6- z v PUMP CHAMBER:hoty_Gj(t.U,e, g SA-O'A' (locate on site plan) Pumps.in working order:(yes or no) y t _ Comments: ...,..- ;f (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 "✓ 1 e r. o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATTIIO^N(continued) Property Address I(Q ( °y=, Owner. Date of Inspection:8 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: leaching trenches, number,length: �p y 1 leaching fields, number, dimensions: ''��` atC� K 4Q overflow cesspool, number: C mments: (note co dition of soil, signs of hyAaulir fail level ofding, condition of vgetatio tc �QG _�1 OVNAa—A 0 No , 2t CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: ; .i 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: ^O (locate on site plan) �'r,•<<-, ; ., 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) r 4 H I . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION(continued) Property Address �O ( ^\P-�l�•. .q � < Q,�`- Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' W� X13 A7 3 YY l oa a A--o S 3 a 6 SC) DEPTH TO GROUNDWATER Depth to groundwater:Vh�t method of ete ' do app itna 'on: � �e Lf (7 (revised 11/03/95) 9 �' AS-BUILT CHECKLIST V LOT NUMBER, STREET NANE ASSESSORS MAP & PARCEL NUMBER (/ LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM, / INCLUDING RESERVE V TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM r LOCATION OF WATER,' GAS, ELECTRIC LINES, CABLE V DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D-BOX STAMP & G I N . / S ATURE V IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN Town of North Andover, Massachusetts Form No. a BOARD OF HEALTH 40RTH 19 DISPOSAL WORKS CONSTRUCTION PERMIT US A l icant' Q pp NAME ADDRESS TELEPHONE ' • Site Location Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Hz JAI CHAIRMAN, BOARD OF HEALTH Fee S^ D.W.C. No. /%Gr dK 10F APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: G /,7, CURRENT INSTALLER'S LICENSE#. LOCATION: t�y 1 SAI l=In S7_ LICENSED INSTALLER: SIGNATURE: ,Z4 TELEPHONE# G ys CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only . $75.00 Fee Attached? Yes I/ No Foundation As-Built? Yes No Floor Plans? Yes / No Approval - Date: 7 TOwI OF NORTH ANQO44ER/ E OARQ OF HEALTH k =! 999 Town of North Andover NORTN � OFFICE OF 32 0�`"e °0 COMMUNITY DEVELOPMENT AND SERVICES ° . p 27 Charles Street North Andover, Massachusetts 01845 �g'vo'IT s��cy WILLIAM J. SCOTTSAC Director (978)688-9531 Fax(978)688-9542 May 19, 1999 Mr. Dufresne Merrimack Engineering Services 66 Park Street Andover, MA 01810 Re: 1641 Salem Street N. Andover, MA 01845 Dear Mr. Dufresne: This is to inform you that the proposed septic plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, y, i is Sandra Starr, R.S. Health Administrator S S/sc cc: Kilcoyne File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover, Massachusetts Form No.2 0�4140RT#f h BOARD OF HEALTH 19 �� • �r' DESIGN APPROVAL FOR 0. CMUSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Test No. 961A Site Location /ol'V/ 1/I') cST. lReference Plans and Specs./ -e'elml3rit- S12 g9 ENGINEER DESIGN D TE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. /J CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. Ib3 Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH /J 3?Oyss`ED b4s�O0 / v��/� /C 19� z 1� 4q APPLICATION FOR SITE TESTING/INSPECTION 7 ORATED PPP' y CI11 9SSAGHU`S Applicant � � 7l �� NAME ADDRESS TELEPHONE Site Location /6`tele ` . 'D —),or � Engineer NAME ADDRESS TELEPHONE ! Test/Inspection Date and Time i CHAIRMAN,BOARD OF HEALTH Fee Test No. 96A I S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 r1ORTH ,E. BOARD OF HEALTH {y.._ /' 19-1I APPLICATION FOR SITE TESTING/INSPECTION i °RATED PPa`�y 'Ss CHUS�� i i Applicant NAME ADDRESS TELEPHONE Y Site Location Engineer tE- NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee ''iti"} Test No. G S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. May-18-99 08:07A Paul D. Turbide, PE/PLS 508-465-0313 P.02 May 18, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 120 Main Street North Andover, MA 01845 RE: Title V review for 1641 Salem Street Dear Sandra, Enclosed find the"Checklist for North Andover Septic System Plans" for the above- mentioned site. Please note that 1 found no `Problem' areas or deficiencies in the plans and design. If you have any questions or comments please feet free to contact us. Sincere Carlton A. Brown, PE/PLS SEPTIC PLAN SUBMITTAL FORM LOCATION: I L21f I_!�A, �2 rz aT NEW PLANS: S $ 0 Ian t/ REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: S NO DATE: DESIGN ENGINEER: DATE TO CONSULTANT: V` *If you want your plans expedited,please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Part Engineering. When the submission is all in place, route to the Health Secretary. FORM 11 - SOIL EVALUATOR FORM Page 1 Data..lr.._ ..................... Commonwealth of Massachusetts �d, n�o , Massachusetts Soil Suitaility Assessn>ler�t_ -site Performed B ' y: ......T�............YID.��� ................................................... ............................ Witnessed By:...„: .::::.::.: K :. H::: ::�. ... :: .. ::: ..........::::::.......... .........................................................�::�.:... Lamdo Add= rl�o�! 7�` Shu 0...n.. ��'`GIfETx �l�cvl�ctE LA Tdwm rn4 /0 AF New Construction ❑ Repair Office Review No ❑ Yes U , Published Soil Survey Available: , Year Published . '� Publication Scale . ..,1�_ &5/O Soil Map Unit ...... ` DrainageClass ....��......... Soil Limitations ................................................................................................... Surficial Geologic Report Available: No Q' Yes ❑ Year Published ................... Publication Scale ....... Geologic Material (Map Unit) Landform .......................................................................................................... ......................................................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No Yes ❑ Within 100 year flood boundary No Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ................................................................__............................................. Wetlands Conservancy Program Map (map unit) .................... .................................................................. 12 Current Water Resource Conditions (USGS): Month A Range : Above Normal ❑ Normal ElBelow Normal N� Other References Reviewed: ��St3� Qva -ORA4 11 - SOIL EVALUATOR YORM Page 2 Deep Hole Number � 2 Data: ' Weather 7r. r.CC,�ar.P�sy Location (identify on site plan) ..........._....._............................................................___...__...._ :�`♦ Land Use _.�_.. ���_..... .___..._... Slope 196) Q �°' Surface Stones ....,N ................. .. _........___ j. Vagbtetion~_..._..t il ..._._.._____..... .,..._................ _._ v _.._......................T........._.........__...................................... ____._..........__ Landform......._....._.6f".._._ . ..._.... ............a___..._........._..._....................................__........................................... .-.___...._...._- position on landscape (sketch on the back( ......�14&..4.49V ,.....___._.._......_..._..._..................._..__.........._ ces from: Distances Open Water Body feet Drainage way_.....y.........[o©_'. feet, Possible Wet Area .?... :.. feet Property Una 15t:?e.1eat Drinking Water Well.?ice?..... feet Other ...••.•••••••••-•...................•• DIEEP OBSERVATION 110LIK LOG OePth from Surfoce Sol(HOftf% Sol Texture Sall Color Sol MratUinO 6� eouidea. ((oohs&) WSDAI IMunoelq (Stnlagn, Como !i Gnvep 5' iso srr� -7 SY►�3 �-�- ........ Depth to Bedrock: Parent Material (geologic( ............................... nenth to Groundwater: Standing Water in the Hole: n.,.'A -Weeping from Pit Face: . µ Estimated Seasonal High Ground Water: ....... YORM 11 - SOIL EVALUATOR FARM Page Z Deep Hole Number. __ Data:.... i.'77 TIme: Weather Location lidendfy on site plenl ------ _._.____ Land Use �.- -L-� =--�- Slope 1961 - Surface Stones ! Vagstadon __ .___taui . _ ....._.___�......._._. _ . w_. _ ...r......_._.......____.............. Landform _.�.�.__..,�,� .__'��.• _..__.M....._.�.�.__.___.._..............__...__...__._......._....__..�....__...._.__....._...._....�.�._ sketch on the back -..--_ •• .: Pa:pion on landscape l 1 1acQ��l_...:.__. Distance$from: Open Water Body moo_ feet Drainage feet, Possible Wet Area z.pe feet Property ungfeet Drinking Water Well. 1°�.. feet Other ........... DEEP A Depth fhan Sutf�oe Soil Hoon Sod TaKW8 6Pd Cola. Sod I�Ar►U" Qi w llnahul WSDAI hdq ISauourr��mnu.Qa�� j2�3G14 �w �L - ss: 10, ter �r�2 Parent Material 1080189161 -_- !L - —w-- -................................ Depth to Bedrock: eenth_to Groundwater: Standing Water In the Hole: t " Weeping from Pit Face? ' a Estimated Seasonal High Ground Water: .... •N FORM 11 - SOEL EVALUATOR FOR Page 3 Cteminadon -for easond IN Method Us d: ❑ Depth observed standing in observation hole...••...••- inches ❑ Depth weeping from side of-observation hole...........— inches Depth to soil mottles •.f inches ❑ Ground water adjustment feet I Index Well Number Reading.Date Index well level Adjustment factor Adjusted ground water level _......... ..._.. _ �.�.._.� _ .._• D�anth of Naturally Occurring Pervious Mate _a Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? I certify that on 5- ldatel I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 16.017. Signatur Date FORM 12 - PERCOLATION TEST COMMONWEALTH 'OF MASSACHUSETTS , Massachusetts Percolation Test Date: -� .-�l.9 Tiine: ........_.......................... Observation Hole # Depth of Perc Start Pre-soak End Pre-soak Time at 12 Time at 9" Time a�, 6" rTime:(91'-661TP pate Min./Inch Site Passed Site Failed ❑ Performed By: Ile � Witnessed By: l Av-f-j�Z v ......................................................................................................... Comments: ................................................................................................... DATE: r ^l G LOCATION, N: (Lz_NGINE; BOF WITNESS. PEF"C0L"T10N TLST BOTTOM DEPTH OF PARC TEST: TIME OF SOAK: _ �' 1 (At IEa minute Icnc) TIME AT 12"' TIME AT 9" b TIME AT E C\,,E;,NIGHT SOAK T1iviE S T,-".F,T-D NcX T D.,'-," SOAK: (.^t ;ems 1 mutes) TIME AT 12 T'IVIS L t 10 P� 319 BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: 4 LOCATION OF SOIL TESTS: lb�! Assessor's map & parcel number: -i7o L ga, OWN ER: �%V�i' IL I t,c��Y"(%TEL. NO.: ADDRESS:___t ENGINEER: Mt 0-'116"t NO.: CERTIFIED SOIL EVALUATOR: Intend— se-o land: residential subdivision, single family home, commercial Re-a'j e`stm L/. Undev o ed lot testing �p g� p 9 N. .. Cation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. . 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1n-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests): 7. Within 60 days of testing soil evaluation forms shall be submitted. TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION Tdersigned hereby certify that the Sewage Disposal System( ) constructed; (/. inepaired: by - <,-n-6fzo I�r.►2�� located at was installed in conformance with the No h Andover Board of Health approved plan, System Design Permit#la� dated y 7 with an approved design flow of*IZ9 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: Engineer Representative Final inspection date: —Z_ ---�� QU Fa Engineer Representative Installer: Lic.#: Date: Design Engineer: �1��J� Date: . 7 2.7 rCWN o t?nd ter, RT,y�Ali]Qt�,�R7 A l �+1.TI r 61999 ' f r r TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 8/16/99 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by George Henderson at 1641 Salem Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. Tho issuance of this certificate shall not be construed as a guarantee that the system will fj4f�jjo.n satisfactorily. Board of Health Inspector TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 8/16/99 This is to certify that the individual subsurface disposal system constructed O or repaired (X) by George Henderson at 1641 Salem Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector vv I� cl) F cl) I-) �'j p Yl X E T rq c y b ; 47 zj A C Cf S S f (7- P 1 1 C I/1.14 t-' IfyLe 7 7. 14 7 X 15 c T-i I Fli/I K 6, 7" r 7q /Y j —7 <7, I PCRC 8 y Ce rlry to 7 7-,Ll I C 6 A, S 7 )C e, N c r 7'-:`f e e, p T P. L r .'kf et i r,c c /0 JI f A —W7-7�K)CE MA DATE AS"' BUILT PLAN OF AV-Z'a a y 5UBSvKFACE DISPOSAL LOCATED IN NORTH ANDOVER , MA , At PREPARED FOR gEAN NOEL MORIN DATE : o c r osE R F 1 9,s 3 SCAU: 40 IF, MERRiMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PLA' NNERS 44 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 o TEL, (617) 475-U55, 373,5721 t 1 1 � i r , ! BOSTON BROOK 1 ' PER PLAN By CYR ENGINEERING SERVICES i 't ! DATE 3-1-79 AND FIRhI FLOOD INSURANCE MAP j PANEL 10 OF 15 JUNE I5,1983 PROOF I r EASEA4',r t l 1 BOUNDARYOF FLOOD ZON .._ w E A" PER FIRM M AD (D 92 1 I • i ACRES + 1 ' 1 1 � 170':1! .i EXT ` ' ✓ } rto Yd27?` ` i � f t i t iV� ;.JGICT�i `��ee _ E X I 'T I j 98 ,Ac I E X I ST I N G F+ ;.0 TO ! j F N t — ABANDONED ` ''� 'i02X8 r-1 t F/38 i ; / LF CSI fELD RE_�,E R v v �0 B,M a /V PAVEMENT pU PLAN OF PROPOSED Si l P ASSUMED I O: ttN ` ?;��- �i�`�1 ` i, EPi ,i,�A, , EXISTING SCALE: 1�0 DATE 2-i-83 REV-3-15-83 - - MjPOSED PREPARED FOR:GEORGE FAR R PREPARED 8Y: i�) FL YA,r 1 V f Cf )+ �) . , , t/. j P. 80 A �5�9 P' AGTOWMA CN ..__ i January 4, 3983 We George parr Rot Lot 55 UICM ^t. 263 Raleight Tavern dune No-Andover#Mass. Dear Mr. Farrs AccordI' k, to records left on fila by our past inspector, Mmmes J. Ma-AW, the sj�o surface disposal 3get On the above 2.1"ia tell lot =at be removed and reaonstruo(4. The present plane on file for thea syatm appear to be adequate for reconstruction. however, this must be confirmed by an on-eito inspection with tho Consormati.on Comission. Very truly ya'.s , *ul.i.tts Key$ M.n. Chadl"M L OT DA � DISRPPROM �A`_ t. 0 V FM g 2..5 'tic .,1jbY. tted plan mut chow a ,11=2: t1w Tot to be servedaarea.,(Waensians l,ot #,abutters b locution and log deep obi.,rva.tion to ties c loutti on Pmd remits per-colati on tests-0.1starwe to ties (� d dosign calculations & (,Pl owlaflons nhov uug raquireA l,cacb ng l �--(e) Location and dt:rEvslol. 3 of iytA ra—includ1mg reserve area f) existing m—d prow ed Ear Ii-xAxs !�(g) location any Tint *r o-3 1 1,"A 1,001 of serge ral.uPOsal sY's m or discl.a �,cr..c;hrsek .w3. ,.Wing �) �1g�'f:�C� grid ty1L'3;'•t'.�5 w� Cie:;..�:�3 't;.�.��IY.XI �:�� r;.� i�w`>Q�: g� �: or 61, --ge di� or" J 'm S,�'�stcm Or Fi'!i.•`�,.'.E.� .,s, .3.�, s..-� l�.r' .�,'�� �v.�,Y 4?� Fp.r.,• I7 �vPfT���. system or �W location of =va L�rvvc! Tot-100 J`rom leaching frac-,-, (A) location of v )i?��'a wl J'°Wl l,c»cl g faoLUty 1—�(m) location of bte;rnulim •k (o) garbage disNsal.s no PSC to be used in construction �) profile of systes -ed tions of base t, Ssi��?�, pipe., p •ic t, , dist -I cation box inlats v.d outlets, distribution. field piping of avation s goomd iotas elcvzAion ixz area sel, e 6-12r,;osal system plan =,, st be prepared by a, rrofes.F o l -EnginEj�or or other authora zcd gay law to propax e h plans of flow, water table, 'yes, depth of tees, \ .. access, pumping cloanout (c) i()t from cellar 'E or L- rand pool, d) 251 from wibsurfase jO.2 Distribration Envies _ ) SIC-'Pe g tc r-I- 0.(!B tl .�, - ..rte . - s-- e.an m-asr.. _ ..r r. .... - _ ww-.+. �r.n-. _w...-.r.-..•.s. w.-w �.n- .w - . - w jse z�a '... Pits L cM.-nag pits are prefkwad TrIA(we tbe pw e x.PAG _ Reg 3-x..2 a) ,fcal cU ati s o f lea.c -g arm- gym sq ft 11.4 b) M. Il �o C) -ft-- e d�age 2% ma1I.11 d) co ater ] c) � ear'p1,adTad ;e@at Olt-ow b) no t.icads iz pipe i1ro . d-box to pipe Laai inn .eAch" ,zeg 15.1 a no glfac c Ai P-0 rinutcas/lmah . •-i ,sYa:`� 900 rte fit 15.4 �, ccrstroction of fiald 15.8 ) Gurfece earld.aage 2 % 3.7 rvl 20, M cell° hd r. g pool Lcivn . �tcs Reg 14.1 s)�e� s a each g €+ -�s. .e a !`� ft 14.3 14.4 ) cam;--.sign ice'c6 ) ast"rAc on 2-4.7 �.. .n..._. . „�.s �� j st%tee ) war.face c image 2% imbill Slope a) slope�x- o be ?acr n) b) ydx X 153 = (to be ahtov-i) S °reg 9.1 a) p7�val 9.6 b) stand-by power Board of Health 8$PTIC SISTEM North An ver a. INSTALLATIGl4 CHECK LIST - LOT'S LIVID DI SUPRUM EXCAVATI 0 eapnst v FAIL OK 1. Distance To: a. Wetlands b. Drains ' ll c.. We 2. Water Line Location 3- No PPC Pipe 4. Septic Tank a. -Tees -_Length & To Clean Ont Covers. b. Cement Pipe to Tank On Both Sides of Tank 10 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Eq -. Amounts c. No Back Flow 6. - Leach Field or Trench a.- Dimensions b. Stone Depth c. Capped lads d. Clean Double Washed Stone' 7. Leach Pi ' a. Dimensions b. Stone Depth c. lash Pads Tees Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. -Final Grafi Inspection 10. Barricading Covered System 11. As Built Submitted _ { a. Lot Location . b. .Dimensions of System Location -,4th Regard-to Perc Test d. Elevations i e; Water Table rt F , 1 V yY � {1 �� C___-�-- � � i � I ! -_ ` � - . � • r � ��� �i '� .� TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 31' SYSTEM OWNER &ADDRESS SYSTEM LOCATION dc� (example: left front of house) L bq ( Sc4 I tw S� - DATE OF PUMPING: QUANTITY PUMPED 150(L) 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) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: ��i" SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) of titanDATE OF OF PUMPING: 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) SYSTEM PUMPED BY: J COMMENTS: CONTENTS TRANSFERRED TO: r-j- ` L J `� Commonwealth of Mass chusetts City/Town ofIv Y �(� ,/ AUG j 5 2008 System P Y Pumping Record To, NER r._ a l' NT Facility Information: System Location, Address 4r I VV City/Tow State Zip Code System O S�. Name: Address (if different from location) City/Town State Zip Code Telephone Number Pumping Record Date of Pumping r Quantity Pumped 5ZI gallons Type of Systerrf\,,/__ ' Septic Tank —Grease Trap Other System Pumped by: Company: Rooter-Man 12 East Dracut Road Methuen, MA 01844 Location where contents were disposed: Signature of Hauler Date: /)1441