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Miscellaneous - 168 CAMPBELL ROAD 4/30/2018
168 CAMPBELL ROAD 2101106:B-0077-0000-0 r I I I I I f f t i� V 1 f`� I O NORTH 1M ° 6453 o, o s • Town of North Andover `�'•:;;o:� �' HEALTH DEPARTMENT ,S$4CHUSt� CHECK#: r� Z DATE: ✓ �11� LOCATION: l�j �(�M f H/O NAME: r CONTRACTOR NAME: -)Ma Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $- I,] ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $__ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer i Commonwealth of Massachusetts RECEIVE® -1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form a -Not for Voluntary Assess ntsTwi 29 2013 ` �e qtr �t�+eR tr/fes: M 168 Campbell Road HEALT", ENT Property Address Debra Donald Owner Owner's Name information is required for North Andover MA 01845 3/29/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil James Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name rm 111 Argilla Road Company Address I Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 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 ❑ Reedit Furtr Evaluation by the Local Approving Authority 3/29/2013 fectoet&—O—a—tu�fy Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. """"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 168 Campbell Road Property Address Debra Donald Owner Owner's Name information is required for North Andover MA 01845 3/29/13 every page. Cityfrown 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: ® 1 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: After permit from B.O.H.,install new d-box 8r waterjet cast iron pipe from septic tank to d-box, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 `T Commonwealth of Massachusetts .' i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 168 Campbell Road Property Address Deborah Donald Owner Owner's Name information is required for North Andover MA 01845 3/15/2013 . every page. Cityrrown State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N . ❑ ND (Explain below): ® obstruction is removed ® Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): High level in septic tank. Obstruction or break in cast iron pipe from tank to d-box.Unable to camera pipe. ❑ 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): I I 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•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t r 168 Campbell Road Property Address Deborah Donald Owner Owner's Name information is required for North Andover MA 01845 3/15/2013 every page. Cityrrown State Zip Code Date of Inspection j 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 forma 3. Other: D-box needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ z 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System f=orm-Not for Voluntary Assessments t r 168 Campbell Road Property Address Deborah Donald Owner Owner's Name information is required for North Andover MA 01845 3/15/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year Nor due to clogged or obstructed pipe(s). Number of times pumped: [I ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure E] ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11!10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'t 168 Campbell Road Property Address Deborah Donald Owner owner's Name information is North Andover MA 01845 3/15/2013 required for i every page. Cityrrown 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: 9 Yes No I ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Z. ❑ 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins-11110 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 168 Campbell Road Property Address I Deborah Donald Owner Owner's Name information is North Andover MA 01845 3/15/2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: I i L Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Two months agoDate Commercial/Industrial Flow Conditions: Type of Establishment: I Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,.etc.): Grease trap present? El Yes ❑ No i Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 a' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 168 Campbell Road Property Address Deborah Donald Owner Owners Name information is required for North Andover MA 01845 3/15/2013 every page. City/Town State Zip Code Date of Inspection . D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1200 gallons How wasuanti measured tank q ty pumped determined? Reason for pumping: Tann flooded, outlet pipe clogged or broken Type of System: ® Septic tank, distribution box, soil absorption system i ; ❑ Single cesspool I ❑ 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•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 168 Campbell Road Property Address Deborah Donald Owner Owner's Name information is required for North Andover MA 01845 3/15/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Inyormation (cont.) Approximate age of all components, date installed (if known)and source of information: 37 years old, 12/1/1976, as built plan Were sewage odors detected when arriving at the site? ❑ Yes .® No Building Sewer(locate on site plan): Depth below grade: 1.4 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.): Unable.to see piping I Septic Tank(locate on site plan): Depth below grade: .4 feet I Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) if tank is metal, list age: j years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Tx 5'x 4' I Sludge depth: 6" i t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 168 Campbell Road Property Address Deborah Donald Owner owner's Name information is required for North Andover MA 01845 3/15/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) i Distance from top of sludge to bottom of outlet tee or baffle 21" Scum thickness 8.1 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 14" How were dimensions determined? Tape Measure 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 baffle ok. Outlet tee ok. Depth of liquid above outlet invert. Cast iron pipe to d-box clogged or broken unable to get camera head in pipe I i Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of.outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 168 Campbell Road Property Address Deborah Donald Owner Owner's Name information is North Andover MA 01845 3/15/2013 required for II every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken. D-box has corrosion holes at liquid level, needs to be replaced. D- -box level &distribution not equal. Evidence of carryover. No evidence of leakage Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i III I i i t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 168 Campbell Road Property Address Deborah Donald Owner Owner's Name information is required for North Andover MA 01845 3/15/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: I leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: I ❑ 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.),- Soil tc.):Soil ok. Vegetation ok. No sign of ponding to surface.Camera inside of pits through outlets in d- box. No standing liquid. { I 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 I Indication of groundwater inflow ❑ Yes ❑ No i t5ins•111110 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 168 Campbell Road Property Address Deborah Donald Owner Owner's Name information is required for North Andover MA 01845 3/15/2013 every page. Cityrrown 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, i 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.): j i i t5ins•11/10 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 168 Campbell Road Property Address Deborah Donald Owner Owners Name information is North Andover MA 01845 3/15/2013 required for I 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 I J� kca.mc � I I I f I I 1 D5`G " Pt�- t It ,/ 145 L4 t5ins-11110 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 168 Campbell Road Property Address ; Deborah Donald Owner Owner's Name information is required for North Andover MA 01845 3/15/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Z Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: '4 .feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 975 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test pit data on design plan shows no water 60" I Before filing this Inspection Report,.please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 168 Campbell Road Property Address Deborah Donald Owner Owner's Name I information is North Andover MA 01845 3/15/2013 required for � every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I I Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for us&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: Left/Right front of house, Left/ rear of hous Left I riht side of house Left I 9 , Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. i Name Address(if different from location) Citylrown State Zi Code Telephone Number B. Pumping Record 1 1. Date of Pumping Quantity Pu p g Date ty mped: Gallons 3. Type of system: ❑ Cesspools) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes B-90 If yes, was it cleaned? ❑ Yes ❑ No 5. Con�oferw l e4 66?AA- --}-z, 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: S. Lowell Waste Water Sign Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 +• Summary Record Card generated on 3/13/2013 9:09:57 AM by Karen Hanlon Page 1 Town of North Andover a Tax Map # 210-1063-0077-0000.0 Parcel Id 17481 168 CAMPBELL ROAD DEBORAH DONALD 168 CAMPBELL ROAD NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zorl 1 Residential Size Total 1.16 Acres FY 2013 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until DEBORAH DONALD Owner 168 CAMPBELL ROAD NORTH ANDOVER MA 01845 ACCIACCA,ROBERT Previous Customer Inactive 12/14/2012 168 CAMPBELL ROAD NO.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17480.0-168 CAMPBELL ROAD Last Billing Date 1/3/2013 3170150 03 Cycle 03 Active UB Services Maint. Account No. 3170150 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 45.60 /1 UB Meter Maintenance Account No. 3170150 Serial No Status Location Brand Type Size YTD Cons 34644348 a Active ERT HH b Badger w Water 0.63 0.63 247 Date Reading Code Consumption Posted Date Variance 12/10/2012 255 a Actual 12 1/9/2013 -42% ! 9/14/2012 243 a Actual 22 10/15/2012 25% 6/13/2012 221 a Actual 17 7/16/2012 76% 3/15/2012 204 a Actual 10 4/14/2012 -19% 12/13/2011 194 a Actual 12 1/17/2012 -46% 9/14/2011 182 a Actual 24 10/13/2011 71% 6/8/2011 158 a Actual 13 7/20/2011 -9% 3/9/2011 145 a Actual 14 4/13/2011 -31% 12/10/2010 131 aActual 20 1/12/2011 -15% 9/13/2010 111 a Actual 26 10/15/2010 117% 6/8/2010 85 a Actual 11 7/15/2010 1% 3/11/2010 74 a Actual 11 4/14/2010 1% 12/11/2009 63 a Actual 11 1/12/2010 -33% 9/11/2009 52 a Actual 17 10/15/2009 27% 6/9/2009 35 a Actual 12 7/20/2009 -6% 3/17/2009 23 a Actual 15 4/29/2009 . -9% 12/8/2008 8 a Actual 8 1/20/2009 0% 10/21/2008 0 n New Meter 0 1/20/2009 0% 9/9/2008 2030 m Manual estimate 10 10/10/2008 -55% MSG 6/6/2008 2020 m Manual estimate 20 7/16/2008 -30% MSG 3/12/2008 2000 m Manual estimate 30 4/11/2008 -35% MSG 12/13/2007 1970 m Manual estimate 50 1/22/2008 -57% 9/7/2007 1920 m Manual estimate 100 10/12/2007 119% I e PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 3/29/2013 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Repair of D-Box By: Todd Bateson At: 168 Campbell Rd. Map 106B Lot 0077 North Andover, MA 01845 The ssuance of this�certificate shall n 1t be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent e Y 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorfhandover.com TOWN OF NORTH ANDOVER f NORTy Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 S1CNU5 Susan Y. Sawyer, REHSiRS 978.688.9540—Phone Public Health Director 978.688.9542—FAX SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: IID &r-Y)060� MAP:_ LOT: INSTALLER: 6 A VIVA6012,0 DESIGNER: PLAN DATE: / BOH APPROVAL DAT ON PLAN: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPE T N: 1/4 DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION Ip e �dm 5�p�`` PRESSURE DOSING - d' D- HOLDING TANK ADVANCED TREATMENT -1p, OTHER Vtr Sho-((vDO o- "1*,) n1'y-'e104 �-> a. s" -��r� �h�e s� COMPONENT SUMMARY FROM PLAN ' GALLON TANK = LOADING OF SEPTIC TANK = GALLON PUMP CHAMBER = LOADING OF PUMP CHAMBER 0re TYPE OF SAS = DIMENSIONS AND DETAILS OF SAS: SITE CONDITIONS ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: Page 1 of 2 l 4 /C C� i •" �°'� S V t'c v VII CIA I b I � r j North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 168 Campbell Rd. MAP: 106B LOT: 0077 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 3/29/13 D-Box DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: j 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: i 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 i i ❑ 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 M 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 inp ressure 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 X H-20 D-Box X Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) i Comments: l Commonwealth of Massachusetts Map-Block-Lot 106.B0077 BOARD OF HEALTH - -- Permit No North Andover BHP-2013-0608 PA. FEE F.I. $125.00 -- ------------------ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-B-ateson --------------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 168 CAMPBELL ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2013-060 Dated March-2-5,29-1-3 ----------------------------------------------------------------- Issued On:Mar-25-2013 BOARD OF HEALTH I Commonwealth of Massachusetts Map-Block-Lot 106.80077 BOARD OF HEALTH ----------------------- North Andover CE ICATE OF C LIANCE THIS IS TO ERTIFY, at the Individual Sew ge Disposal stem (Repair) I by Todd Bateson --------------- -------------------------------- ------- --- ------------------- ----------------------- I aller I at No 168 CAMPBELL ROAD 168 CAMPBELL has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. 13HP-20137060 Dated---March 25,201.3_ ----------------------------------------------------------------- Printed On:Mar-26-2013 BOARD OF HEALTH G � .......................................................................................................................................................................... 168 CAMPBELL ROAD Reference No: BHJ-2005-000003 Permit No: BHP-2013-0608 Department: ................................... North Andover BOARD OF HEALTH ............. FFee Type: Account No: .1001001.1.5.0510.00. .................................. : DWC-Component Repair PERMIT Receipt No: REC-2013-001251 .-....................................................................................... .----...................------------ Paid By: Paid in Full On: Mon Mar 25,2013 Todd Bateson .................................... Received.By............. Check No: 7301........................ Lisa Blackburn DEPARTMENT'S COPY Amount: $125.00 ........................................................................................................................................................::::::::: A OORT{t Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE �� - O , $250.00—Full Repair RTH ANDOVERMA 01845 �,'�•...,. $125.00-Component SSACMUSE 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 to move your BApair or replace an existing system component—What? O x cursor-do not use the return A. Facility Information key. Address or Lot# f City/Town o . e ilei,-- RECEIVED 2.- *TYPE OF SEPTIC SYSTEM*: E] Pump ravity(choose one) I. % Z5 2013 ***If pump system,attach copy of electrical permit to application** TOWN OF NORTH ANDOVER conventional System(pipe and stone system) I HEALTH DEPARTMENT ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information ,.... Name Address(if different from above) '7 Ghdeot".,+ Nf City/Town State Zip Code Telephone Number 3. Installer Information 1 rBATESON ENTERoRIS€S,-ING. Name Name of Comp111 ARGILLA ROAD /// //, r_y - MIME%MA 01810 ; Address City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information 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 g G`r FIT;,N Applicati-oh. Disposal :System M,•:,f .`:•°o .. TODAY'S DATE A Construction -Permit _ TOWN OF ' `';�° rf� * •ORTH AND OVERMA 01845 $250.00--Full Repair f '4�'^,,ry.►R $725.00.-Component SSACHUS PAGE 2 OF 2 A, Facility•Information continued.... 5. Type-of Buildin esidential 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 Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place the system in operation until a Certiricate of Compliance has been!ss this Board of Health. Nam Date Application Appr a y: (Board of Health Representative) -2, _:2 -7-I5 Name ' Date " Application Disapproved_ r the following reasons: For Office Use Only: 1 Fee Attached?: Yes No 2.. ProjectMariager Obligation Form Atiach'ed? Yes No 3.: Ifsot Attach copy ofElectrical Permit'. Yes No 4. Foundation As Built.?(new construction-ronly). Yes No (Same scale as approved plan) ° 5. Floor Plans?(hew construction only): Yes_ No -�pplrc�tibn'for vispotal SAteriY:Ponstruction Permft*Page 2 of 2 i YSTEM INSTALI;EE PRGf ECT MANAGEMENT OBLIGATIONS SEPTICS. As the North Andover•licensed installer for the const motion for the septic system:for.the prbpe y.at For plans by (Address of septic system) Jdated /4d.- Relative to the.application o Acid dated (installer's name) A-2—F.. Dated With revisions o s ate (Last revised date) I understand the following obligations for management of-this project: ; 1. As the installer,I am.obligated to obtain.all permits and Board ofHealth approved plans 'l dot to ;performing any.:work on a site. I must have the roved:ilans and the permit on site when any work is beinvone. 2. As the installex,.I.miist..call.for any and all'inspecdons: I£homeowner,contractor,.project manager,or any other person not associated with my company schedules aninspection and the system is not ready,thein ''cable. item three-shall.beapplicable. As.the installer,-I�atm•xegtiired to.have.th'ie oecessaty work completed prior:to the.applicable inspections as iddisited beloW I iiftdef'stand that re nesting a.ninspection without comtiletion of the items in accordance with Title 5 and the Boafd of l4ealth lte ilations iinay rest f in a$50'0(7 fine being levied against me..and/or a,. Bo'tfom ofBeS Generally,this-is the first.r+1`�it�spectlon unless.there is a detaining wall,which shouldbe�do ie Atst Theinstal.I0:snust tggpest the Ispeci ios but does not have to be present.. b. Final-Constructori.Inspeetioti—Engineer mils"t fits do them inspection for elevations;ties, etc. As-�iiilti of•vetbal OK(or e-mail•to;liealtlideptownofriorthandomb ver.cofrom the engineer must be stibuiitted•to.the.Bo4d-ofHeaMt ,aAo..'w�Wch.instaher.cahls'for:an inspection time. Installer must bepresent for this.inspection, with a pump ystein,.,4 electrical pt ust be ready and able to cause p.iimp.to.v�ork and;4a=nri.to futietion.. , C. FindVGGtado—Ihstaller must request inspection v�hen all grading is complete...,Installer'does not have to be on-site. ' 4. As-the ins taller,'I understand that only I•may pttform the.work"(otherthan cim+pk excavation)and I am required to complete,the-instaMation of the system identified in the attached application for installation: I finrther undetgand.that work done by others uiiliceiised to iristalf se itic systems•iii North Andover can constitute reasons for deival of the stern and&&`.`- vocation or Susi erision of•my lieense•to operate in.the Tbwn.of North Andover'sioiuficant fines to all eisons-involvedpare also possible. 5.. •As the.instiller,•I understand tlnat:I:mtut.-be-on site during the.perforrnance of the following construction. steps:.. a: propel elevation of the a rcavadon has been reached A Inspection ofthe'sand and stone'to be used. c. Final nnspecdon by Board of ffealth staff or consultgnt. d. Instahation,oftank,D-Box;pipes,stone, vent,pump chAmbeA retaining walland other components. ' 6. as thg installer,I uriders=d that I amsblel_ responsible for the installation of the system as per the =rob�d.hilans No instructions b�thehomeowrier,general contractor or any otlier1persons shall-absolve me gf N;obligation. Undersigned Uceased Septic.IA$14llec. : (Today's Date)` ,r TOWN OF ORI'H ANDUV!✓k UA i k Q� ,p�' SYSTEM UMPINQ RBCopjj SYSTEM OWNER ADDRESS SYS, LOGATIAN t DATE OF PtfMp(Np; p "...._QUANTITY PUMPED: VtSSPOOL: NO sooc Tmk: NU YES �,..........Y ES v N^ rUKu OFA SERVICE: itovrlN!~„j�M RU NCY ���rrrRVA'rtoNs: RECEIVED GOOD CI. ONDITION „.PULL.'1'U COVER ►vY ot�AsB '_" ' SAMOS IN PLACE. _.... APR - 4 2005 , sXC6�SS7VE SOLIDS_.,.._ FLOODEDLEACMeLD RUNBACK . SOLID CARRYOVER_.... OTHER EXPLAIN TO N O NORTH TM OVER. ".1 System VUMMENTS. .... ._._.,._.. .:... . 4ury I'EN'I's rKANSF'lrRRfiD fU . .. ....0?� v C) . i RECEIVED TOWN OF NORTH ANDOVS}, FEB 0.2 2005 UIQ tl. I SYSTEM PUMPINU UCOFLG TOWN OF NORTH ER HEALTH DEPARTMENT L .. SYSTEM OWNER ADDRESS SYSTEM LOCATTON /)a Lk Jk) DATE OF PUMP1NQ: _... .__._._QUA NTTTY PUMPED:_._•_/dD� t.:WPOOL: NO..... YESC .. Sopa A ttnk: NU YES NA rUK[;ON Sl:Rv10E: kouTlNk _ _ tMERUE;NC'Y UbSERVATION9: , GOOD CONflITION V .POLI, •Tyj DOVER e� QYA CSE ___ BAPPLES IN PLACE. . LWHF 5XCEBSIVE SOLIDS.—.. FLOODED D RUNBACK SOLID CARRYOYER,_._.OTHER EXPLAIN System Pumpcd by CPO i VUMMENTS. ,.'VN PEN'I'S rKANSF'bKK&) 1'U �U �p . /�/j��` � j7 /�� i TOWN OF NO H ANDOV & uA rt SXT PUMIN(',r RCC) Nov - 3 2004 SYSTEM OWNER.& ADDRESS 'Q T 4 ANDOVER SYS�'EM LOCA ON IV L-14 1,9 • 14 DATE OF PUMPING: b" ZZ'O ANTITY PUMPED: .t 7M Z11 C!?,SSPo()L: P__ YES NATURE OF SERY[CE�ot-vj-1 _._.__EMERGENC 1' 0BUIRVA'nONS: 0001)CONDITION HEAVY CAS.E ---._... FULL -WCOVERHF-AV} __ BAFFLES IN PLACE. I.EACHWIELD RUN$ACK EXCESSIVE SOLIDFLOODED -._. SOLID CARR YQVE _ OTHER EXPLAIN Syewm pwnpcd by COMMENTS. � CUN MNTb TKANSFERR,ED 'rU i op�E� FORM 4- SYSTEM tApARp p EP 2� 1995 � S Cottunonwealth of Massachusetts Massachusetts System Pumping Record System Owner Systern Location Date of Pumping: Oac, Quantity Pumped 1�J gallons Cesspool: No lam' Y'es ❑ Septic Tank: No ❑ Yes System Pumped by- � _ License #: Contents transferred to: - �- Date Inspector i SEP SUBSURFACE SEWAGE DISPOSAL SYSTEM INS/ C O } Address of property (6e� �Q tM� " ��• '" VQ� ' '`-t owner's name ` Date of Inspection r- 1 "^`O V, PART A CHECKLIST Check i the following have been done: Pumping information was requested of the owner, occupant, and Board of H th. None 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 s em recently or as part of this inspection. As b • lt plans have been obtained and examined. Note if they are not a ilable with N/A. Th acility or dwelling was inspected for signs of sewage back-up. T site was inspected for signs of breakout. All ,system components, excluding the SAS, have been located on the 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 slJe, depth of scum. E/ The size and location of the SAS on the site has been determined based on fisting information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential a number of bedrooms number of current residents -t-=� garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: �J� 3 Water meter readings, if available: e4.4'1% Last date of occupancy (�c (e,q / -7 a GENERAL INFORMATION Pumping records and source of information: System pumped as part of inn�ssc n e { es or no if yes, volume pumped l ��S Reason for pumping: Type 9,f,-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. Source of information: Ip ��� 0 r � a _ i � `w bb, (( lc. C� JU�i �'� VO Sewage odors detected when arriving at the site, yes or no g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) Lf depth below grade: material of construction: concrete metal FRP other(explain) dimensions: k r x S f�© g10L4,S 7%;Asludge depth f_:�V_ " distance from top of sludge to bottom of outlet tee or baffle scum thickness Tit 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 leakag rec mmen ation fo epa ' s etc. C, (' DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evi ence f le k i to or out ,pf oxo, rec ©�gion fo r ais, etc. ) { _ v PUMP CHAMBER: y ©y'e- (locate on site plan) V pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued 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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, con tipn4 f veget io rr�ecommenndUation forg5ntgWce .o� rep�r�etc. ) CESSPOOLS (locate on site plan) : V�Q\AC) number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) L 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 5� `2�1S 4 if ;, .{��a =-0�6� 11 rr 0 _ Sr4rr boo TA-* i 4f 6 o`r b4o 5`7 13 11 I tr ic �. .� G. �,�,�-� ► -tea ' � G o� Q)� �a DEPTH TO GROUNDWATER Uw""f"" depth to groundwater method of determination or approximation: ©v\ 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate es no or not determined Y N or ND . Describe basis of In i y ( ► ► ) determination in all instances. If "not determined", explain why not) N Backup of sewage into facility? N Discharge or ponding of effluent to the surface of the ground or surface waters? N Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? 'y Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal . cracked. structurally unsound. substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: ►" below the high groundwater elevation? -Al within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of aP ublic well? /V within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply 1 well? y" less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector 7 v -Z• _ Company Name Company Address e3l ) Certification Statement I I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenanc of on-site sewage disposal systems. C eck ne: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date 6-46-95- g,__, Original to system owner Copies to: Buyer (if applicable) Approving authority I �.�, tom✓, l� � z W moi►-.. �� �-�- ���euja o /� v Commonwealth of Massachusetts Map-Block-Lot o •tea 106.B-0077 -- - Board of Health PernritNo * BHP-2005-0039 North Andover ----------------------- P.I. FEE $125.00 F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby anted John DiVincenzo to(REPAIR-PIPE ONLY)an Individual Sewage Disposal System. at No 168 CAMPBELL ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2005-0039 Dated February 142 2005 ------------------------------- ---------------------- Issued On:Feb-14-2005 Board of Health ............................................................................................................................................................................... ^` "°'" Commonwealth of Massachusetts Map-Block-Lot 4 �6� 106.6-0077- �' Board of Health ----------------------- North Andover �• �} M CERTIFICATE OF COMPLIANCE A tAu�' THIS IS TO CERTIFT,That the Individual Sewage Disp b John DiVincenzo ` Installer ��-GP y '' at No 168 CAMPBELL ROAD h s �yin,� (�t• c,:.�r ------------------------------------------------- --------------------------------- ------------ has been installed in accordance with the provisions of TITLE 5 of the State ,�.: l l `�_ the application for Disposal Works Construction Permit No._BHP-2005-0039 IK . T ----------- Printed On:Feb-14-2005 oartt ot�eaa4ttt Commonwealth of Massachusetts Map-Block-Lot 106.B-0077- 4" Board of Health rerm;trro BHP-2005-0039 North Andover P.I. FEE �C�au�j• F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John-DiVincenzo to(REPAIR-PIPE ONLY)an Individual Sewage Disposal System. at No 168 CAMPBELL ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2005-0039 Dated February_14, 2005 ----------------------- --- Issued On:Feb-14-2005 Board of Health ----------------------- ............................................................................................................................................................................... ! + Commonwealth of Massachusetts Map-Block-Lot .v �0 106.B-0077- Board of Health ----------------------- R y At North Andover �•,_,�res" � CERTIFICATE OF COMPLIANCE THIS IS TO CERTIF That the Individual Sewage Disposal System (REPAIR-PIPE ONLY) by __John DiVincenzo ---------------------------- ---------------------------- ----------------------------------------------- Installer at No 168 CAM-BELL ROAD has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No._BHP-2------0039 Dated__-February_14,-2005__ Printed On:Feb-14-2005 Board of Health own of North Andover ,. Health Department Date: Location: / (— (Indicate Address,,if Residential,or me of Business) Check#: Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ U eptic Disposal Works Construction(DWC)$-Id—,6 � ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrasWSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) Health Agent Initials 678 White-Applicant Yellow-Health Pink-Treasurer f, TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES �a°•�;``° aoo� HEALTH DEPARTMENT 400 OSGOOD STREET ;,%, _ r•` NORTH ANDOVER, MASSACHUSETTS 01845 'SS CHstd � U 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.9542—FAX Public Health Director healthdept@townofnorthandover.com-e-mail j www.townofnorthandover.com-website APPLICATION FOR DISPOSAL WORKS CONSTRUCTIO EIV ED r4 2005 c FEB 1 DATE: � � � � TOWN OF NOPTH ANDOVER HEALTH DEPARTMENT LOCATION: A� L"OJ}'Y! �j-� `l �` el LICENSED INSTALLER NAME: p h a) �. V ; y►�_ n'� PLEASE PRINT SIGNATURE: t ELEPHONE# CHECK ONE: FULL SYSTEM REPAIR: ($250) COMPONENT REPAIR(indicate what parts): P1 P-( 7ci/i Ta e V ($125) Px 6a * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As-Built Plan. $250.00 or$125 Fee Attached? Yes No Project Manager Obligation From Attached? Yes `� No Foundation As-Built? Yes No Floor Plans? Yes No Approval of Health Agent — Date: z, hylz;)-5 sem/ / INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for/the construction of the septic system for the property at & O �Ce�1 -e ` ( relative to the application of dated for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necgssary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction.steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersi ed cens S ti Instal r Date: Di/ osal Works Construction Permit# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' S I Q« A,,,Sa =meq e 3 cio ►fl- ��roa 8 �r 8 i = 4t60 Q o'er --�0 ,�� ?� VIA- DEPTH IPDEPTH TO GROUNDWATER � i 0ykkq.v11.y -% depth to groundwater f method of determination or approximation: ©v\ ILL pV\gLAJ i . I I . I Address Title of File Page of Date File Open: Date file closed: . Doc Document/Action Title Date of Refer to other Purpose of Document/Action and note action Document/ document/ — Nun Action Department Board of Appeals — Board of Health Planning Board-_ Conservabion Commission — B oildinn 6epartr,ent �''— TO: NORTH ANDOVER, MASS '( G" 19r BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at �o� l C'/1 /ti9e'bed 'R'D . North Andover, Mass. 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