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Home My WebLink AboutMiscellaneous - 169 GRAY STREET 4/30/2018 Jr 169 GRAY STREET i 210/107_D-0012-0000.0 V i i i i i I I� l � StigT�D`646 � mow, J ^;r / fix. G� PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: December 20, 2017 This;is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box Repair of On-Site Sewage Disposal System By: Peter Breen At: 169 Gray Street Map 107.B Lot 12 North Andover, MA 01845 Th uanc s ce ficate shall not be construed as a guarantee that the system will function satisfactorily. B is . LaGrasse, CEHT Director of Public Health I 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov c • S�q'f�ED I6g6 . �O North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 169 Gray Street MAP: 107.D LOT: 0012 INSTALLER: Peter Breen DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: D-Box Only- December 19, 2017 INSPECTIONS TANKINSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ [Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: 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 a ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: Equal Dist. Flow Tested — B. LaGrasse 01 SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE i ❑ Lamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN r CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ®. Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Commonwealth of Massachusetts Map-Block-Lot 107.D0012 BOARD OF HEALTH Per------------- • Permit No North Andover BHP-2017-1116 --------------- -- PA. FEE F.I. $175.00 0 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted peter Breen to(Construct)an Individual Sewage Disposal System. at No 169 GRAY STREET as shown on the application for Disposal Works Construction Permit No. BHP-2017-`111�Da ed—Deceh!erfl8,2017 – --------- --- -------- `!�Vic..✓ ! ------------------------------------------ -------------------------- IssuedOn:Dec-18-2017 BOARD OF HEALTH . s °„ 107.D0001212Lot Commonwealth of Massachusetts Map-Block-Lot ----------------------- BOARD OF HEALTH Permit No North Andover -BHP-2017-1116-------- -------------- P.I. FEE F.1. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter B-reen - - --------------------------------------------------------------------------------------------- to(Construct)an Individual Sewage Disposal System. at No 169 GRAY STREET as shown on the application for Disposal Works Construction Permit No. BHP-2017-111 Dated December 18 2017 ----------------------------------------------------- Issued On: Dec-18-2017 BOARD OF HEALTH Application for Septic Disposal Construction Permit — TOWN SOvF stem TODAY'S 9-DATE �a 1 NORTH ANDOVER, MA 01845 $ 00-Full Repair $17755..00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on,the computer,use ❑Repair or replace an existing on-site sewage disposal systemrr only the tab key Repair or replace an existing system component—What? ( y 0 y' to move your cursor-do not use the return A. Facility Information key. Address or Lot# Z6 9 6/121C/ 5 City/Town 2.-*TYPE OF S RTIC SYSTEM*: DEC *: UC 8 2017 ➢ ❑ Pump yGravity(choose one) TdKWOFNORr ***If pum s stem, a h copy of electrical permit to application*** WANDOV�R ➢ CoHE4LTW DEP conventional System (pipe and stone system) ARTME ➢ 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) ------.__----------_-----➢--C-°rz.ressure-Gosed-(D=Box-Present):S:A:S:----,-------__—.�,------------_��--------------- ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) Wbatis the Make? Wbatis the Model. 2. Owner Information Name Address(if different from above) 6 2af 0/ 1/r CityfTowrT State Zip Code Email address Telephone Number 3. Installer Information u ,v✓ 0 6-f--r 6127 . k C- Name Name of Company 6 S Address JA/ 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 • =' Application for Septic Disposal System s Construction Permit — TOWN OF TODAY'S DATE NORTH ANDOVER MA 01845 $ 00-Full Repair - + $17755..00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approve . Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office.Use Only: 1. Fee Attacbed? Yes No 2. Project Manager Obligation Form Attacbeda Yes No 3. Pump System? Ifso,Attach copy ofElectrical Permit Yes No Applican t received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvalletter, aUpaperworkreceived? Yes No Missrrlg.• 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) G. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 aoRrti 8 '13 5 O Town of North Andover `�'•�;,,,> HEALTH DEPARTMENT,ss.4c USt1 CHECK#: 7879 DATE: is L61� LOCATION: 1( � H/O NAME: u r CONTRACTOR NAME: /•'2 .-L`2/� / �� 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing -�d $ ❑ Septic-Design Approval f��/( $ Septic Disposal Works Construction(DWC) $ /❑` Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ /`- Hea gent Initials White-Applicant Yellow-Health Pink-Treasurer i r SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) '^J For plans by (Engineer) Relative to the application of (Installer's name) And dated (Original ate Dated ( ay s ate) With revisions dated (Last re%rised date) 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 airy work is being done. 2. As the installer,I must call for any and allinspections. If homeowner, contractor,project manager, 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 necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company_, a. Bottom of Bed–Generally, this is the first (1'�inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection–Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to:healthdept@northandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done 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. h. Inspection of the sand and stone to he used c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank,D-Box,pipes, stone, vent,purnp 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 dais obli ag tion. Undersigned Licensed Septic Installer: A �oda 's Date) E:!--(f– a, a-L' — (Name–Print (Name–Signe T 577 MAIN STREET HUDSON,MA 01749 800-499-1682 WIXDRIV-ER I EN VIR4NMENTAL RLCEIVED SEP 2 1 2005 TOWN OF NORTH Ahq )OVER HEATH DEPAR"ME',T I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: MURPHY,FRANCIS PROPERTY ADDRESS: 169 GRAY ST.,NO.ANDOVER MA 01845 ADDRESS OF OWNER: SAME it (IF DIFFERENT) DATE OF INSPECTION: SEPTEMBER 14,2005 NAME OF INSPECTOR THOMAS CHIGAS i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y C t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 169 GRAY STREET NO.ANDOVER,MA 01.845 REC�� Owner's Name:MURPHY,FRANCIS Owner's Address: 169 GRAY STREET NO.ANDOVER,MA 01845 SEP 2 12005 Date of Inspection: SEPTEMBER 14.2005 TOWN OF NORTH ANUUvEk) Name of Inspector:(please pr' THOMAS CHIGAS HEALTH DEPAPTMF�N Company Name: Windriver '`�rrmentx Mailing Address: 577 Main Street Hudson,MA 01749 Telephone]dumber:800-4994682 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: YES Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: SEPTEMBER 14,2005 The system inspector shall submit a copy of d 4sispection 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 169 GRAY STREET NO.ANDOVER,MA 01845 Owner:MURPHY,FRANCIS Date of Inspection:SEPTEMBER 14.2005 Inspection Summary: CheckoB,C,D or E/ALWAYS complete all of Section D A. System Passes: YES 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: NO 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. NO 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: NO 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): NO broken pipe(s)are replaced NO obstruction is removed . NO distribution box is leveled or replaced ND explain: NO'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): NO broken pipe(s)are replaced NO obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 169 GRAY STREET NO.ANDOVER MA 01845 Owner:MURPHY.FRANCIS Date of Inspection:SEPTEMBER 14,2005 C. Further Evaluation is Required by the Board of Health: NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is Th—Ing to protect public health,safety or the environment. 1. P System will ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the Y system is not functioning in a manner which will protect public health,safety and the environment: Y t N/A Cesspool or privy is within 50 feet of surface water N/A 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: NO 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. NO The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. NO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. NO The system has a septic tank and SAS and the SAS is less than 1.00 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. I 3. Other:N/A i i Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property rh'Address: 169 GRAY STREET P NO.ANDOVER,MA 01845 Owner:MURPHY,FRANCIS Date of Inspection:SEPTEMBER 14,2005 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 N/A Liquid depth in cesspool is less than 6"below invert or available volume is less than%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. NA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 NO the system is within 400 feet of a surface drinking water supply NO the system is within 200 feet of a tributary to a surface drinking water supply NO the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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: 169 GRAY STREET NO.ANDOVER MA 01845 Owner:MURPHY,FRANCIS Date of Inspection:SEPTEMBER 14,2005 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? N/A 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 NO Existing information.For example,a plan at the Board of Health. 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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 169 GRAY STREET NO.ANDOVER,MA 01845 Owner:MURPHY,FRANCIS Date of Inspection: SEPTEMBER 14,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 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 [if yes separate inspection required] Laundry system inspected(yes or no):N/A Seasonal use:(yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):NO Last date of.occupancy:CURRENT COMMERCIALQNDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:OWNER Was system pumped as part of the inspection(yes or no):YES If yes,volume pumped: A00gallons--How was quantity pumped determined?SIZE OF TANK Reason for pumping:CHECK TANK'S INTEGRITY TYPE OF SYSTEM YES Septic tank,distribution box,soil absorption system NO Single cesspool NO Overflow cesspool NO Privy NO Shared system(yes or no)(if yes,attach previous inspection records,if any) NO Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) NO Tight tank Attach a copy of the DEP approval N/A Other(describe): Approximate age of all components,date installed(if known)and source of information: 15 YRS,OWNER Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 GRAY STREET NO.ANDOVER,MA 01845 Owner:MURPHY,FRANCIS Date of Inspection:SEPTEMBER 14,2005 BUILDING SEWER(locate on site plan) Depth below grade:21" Materials of construction: cast iron 4"40 PVC other(explain): Distance from private water supply well or suction line:N/A Comments(on condition of joints,venting,evidence of leakage,etc.):THERE WERE NO SIGNS OF LEAKAGE,SOILS WERE CLEAN AND DRY. SEPTIC TANK:YES(locate on site plan) Depth below grade: 12" Material of construction:YESconcrete 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: 101L X 51W X 5'11 OUTLET INVERT(a)50"=1500 GALS Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle:26" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle:5" Distance from bottom of scum to bottom of outlet tee or baffle:14" How were dimensions determined?ROD,AND RULER Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):THE TANK WAS PUMPED AND THERE WERE NO SIGNS OF LEAKAGE,SOILS WERE CLEAN AND DRY.THE INLET BAFFLE IS CEMENT AND THE OUTLET BAFFLE IS SCH40 PVC,ALL INTACT AND IN GOOD SHAPE. GREASE TRAP:NO(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 l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 GRAY STREET NO.ANDOVER,MA 01845 Owner:MURPHY,FRANCIS Date of Inspection:SEPTEMBER 14,2005 TIGHT or HOLDING TANK:NO(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.): i DISTRIBUTION BOX:YES(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:0" DEPTH BELOW GRADE:24" 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.):THE 16"X 16"D-BOX IS LEVEL AND EQUALLY DISTRIBUTING.THERE WERE NO SIGNS OF LEAKAGE OR FAILURE,SOILS WERE CLEAN AND DRY.THERE IS ONE INLET AND TWO OUTLETS. PUMP CHAMBER:NO(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i i Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 GRAY STREET NO.ANDOVER,MA 01845 Owner:MURPHY,FRANCIS Date of Inspection:SEPTEMBER 14.2005 SOIL ABSORPTION SYSTEM(SAS):YES(locate on site plan,excavation not required) If SAS not located explain why: P y i Type Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: YES Leaching fields,number,dimensions:TWO LEACHLINES,10'W X 5011,LEACH BEDS 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.):THE LEACH LINES WERE SCH2O PVC AND IN GOOD CONDITION.THERE WERE NO SIGNS OF BRAK-OUT OF FAILURE IN OR AROUND AREA,SOILS WERE CLEAN AND DRY. CESSPOOLS:NO(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:NO(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.): c , ` Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 GF AY STREET NO.A]qDOVER.MA 0 Owner:MURPHY FRAr CIS Date of Inspection:SEPT MBER 14 2005 SKETCH OF SEWAGE AL tS M Provide a sketch of the se ge di s including ties to at least two permanent reference landmarks or benchmarks.Locate all we s wit ' Locate where public water supply enters the building. Al a, lgcme • k A 4o -"1 .25 `-n 1-0 1 I 1-a V c-sy/ I i 4o �I r � 1 • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 GRAY STREET NO.ANDOVER,MA 01845 'Owner:MURPHY,FRANCIS Date of Inspection:SEPTEMBER 14.2005 SITE EXAM Slope:NONE Surface water:NONE Check cellar:YES Shallow wells:NONE :Estimated depth to ground water 81+(aaarox)feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: YES Observed site(abutting property/observation hole within 150 feet of SAS) YES Checked with local Board of Health-explain:INFORMATION NO Checked with local excavators,installers-(attach documentation) YES Accessed USGS database-explain:MAPS You must describe how you established the high ground water elevation:THE HOME HAS 8'FEILD-STONE FOUNDATION WITH NO SUMP PUMP AND THE BASEMENT WAS DRY.WHILE DIGGING IN YARD (7a,DEPTHS OF 314'THERE WERE NO SIGNS OF(EHSGW)IN OR NEAR SYSTEM.THERE WERE NO SIGNS OF ABUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 150'FROM SYSTEM. vv. ♦rlvl Irnl\nl.l I VV/\ SILTATION CONTROL FABRIC ATTACHED TO 4'-6" WOODEN STAKED HAYBALES STAKES SILT FENCE BEHIND 2 WOODEN STAKES EXISTING STAKED HAYBALES PER HAYBALE (TYP.) GRADE x --�- MOUND SOIL AGAINST FENCE 3'-0" SILTATION CONTROL FABRIC FLOW 1 w 6" TO EDGE 4'-6" WETLANDS ,. WOODEN n •-,, BELOW STAKES ' t ` GRADE s " .SIL TA TION CONTROL . FENCE. AND STAKED HA YDALES DETAIL N. T.S. PLAN OF ND IN ]VOR.111 ANDO VER MA SHO WING PROPOSED SWIMMING POOL PREPARED FOR FRANCIS J. & ELLEN P. MURPHY 169 GRAY STREET TERING FIL TER NORTH ANDOVER MA all Tw, , DATE MARCH 21, 2011 REV.: OCTOBER 13, 2015. d SCALE. 1"20' of 0' 10' 20' 40' 60' MERRIMAC K ENGINEERING SERVICES 66 PARK STREET. ANDOVER MASSACHUSETTS 01610