HomeMy WebLinkAboutMiscellaneous - 173 BRIDGES LANE 4/30/2018b ca
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SEPTIC SYSTEM INSTALLATION
Is the installer licensed?
1
NO
Type of Construction:
'NEW
REPAIR
New Construction: Certified Plot Plan Review
YES
NO
Floor -Plan Review
YES
NO
Conditions of Approval from Form U
YES
NO
SEPTIC SYSTEM INSTALLATION
Is the installer licensed?
YES
NO
Type of Construction:
'NEW
REPAIR
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:�,
NO
DWC Permit Paid?
I
NO
DWC Permit # Installer:
P , �,�._, �,,
DWC Date
Begin Inspection: YES NO
Inspection:
Passed: By:
Construction Inspection:
Needed:
As Built Plan Satisfactory: YES
Approval of Backfill:
Final Grading Approval:
Date: By:
Date: By:
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
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Claim # 3048746
Advantage Claim Services Adjuster Assigned: G Guarente
522 Chickering Road #B
North Andover, MA 01845
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health o1r/
Inspector of Buildings Board of Selectmen
Town Hall Town Hall
North Andover, MA 01845 North Andover, MA
Re: Insured: Robert Cerchione
Property address: 173 Bridges Ln.
North Andover, MA 01845
Policy #: 3048746
Loss of: 2014/03/01
File or Claim No. AD 9975
Claim has been made involving loss, damage or destruction of the above
captioned property, which may either exceed $1,000.00 or cause
Mass. _Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any
notice under Mass_Gen _ Laws, _ Ch. _139_Sec._3B is appropriate please
direct it to the attention of the writer and include a reference to the
captioned insured, location, policy number, date of loss and claim or
file number.
G Guarente
Title: Adjuster
On this date, I caused copies of this notice to be sent to the persons
named at the addresses indicated above by first class mail.
04-30-14
Signature arld date
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CHECKLIST FOR CARBON MONOXIDE
Location of Incident:_1�73;, . ?jam 616e5 Zig Date of incident
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QUICK CHECKLIST OF OCCUPANTS '
Headache yes no OC.- Fatigue yes no oc
Nausea yes nom Dizziness yes 1165Z7Confusion yes no
Are any members of the household feeling ill? yes nom
Do the residents feel better away from the house? yes noaL
Since the detector's alarm went off, what have you done?
Shut- off carbon monoxide sources yes noD,—
If yes which sources
Let in fresh air? yes _r.71- no
If yes how did you let the air in &,)i 12 c/o ccJ !w o tz
I low long did you let the air in 6
PPM reading ambient outside the dwelling
I-lighest PPM reading in the dwelling
Carbon monoxide detector present? yes_ no
If yes list the number of detetors locations and make, and serial number of each below.
2.
3.
4.
Which detector(s) by number above activated? /
SOURCE CHECKLIST LOCATION PPM READING
Chimney clogged flue, blocked opening G FPS
Fireplaces) Natural gas, LPG, Wood(indicate type for each fireplace)
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Gas Appliance (if.Gas Company on Scene they can perform this check)
(IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING)
refrigerator
stove
vent over stove
clothes dryer
water heater
furnace ,
Oil burner
car garage
Entranceway from garage to house
Name of individual operating the COmonitorM
Person completing the Checklist LTA /'yj, hD eAlcpj"
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M��GACHUSETTS �A53ACHL!S[�lT�
FIRE TNCIDE�T R!�PORT 5TOTE F7HE NARSHDL
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( ( owner name las,first`mi { address ! re}ephu/e |
| | method of alarm | \ Jistric|�
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| numbers of injuries ( numbcr u� fatalities
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| method of extinquishment | | lsvol o fire nriqin \ }
M | MllF 2D-EXT�CDNT_UNDET{]�,NOT�Ep -OF'ORI{`lN U�DElERMIN�D__ | 0 |
{ numbers of storios | | cnnstruction type | |
| ��TERM/NO�REP _ 0{ lERMIl�[�0_{}R i%.'!
| extent of flame (-.I | � extcnt nf smu�c C,amaop
N \ I��0-� �ORTB �i-��T�M��D��1�|
| detector performance i | �prin|�ier porforma�"�- — - --{
P i UNDERTERMiINED/NOT_REPORTEDDEJ�!
1 if smnke spread 1 material gpneratinq|fnr� | }type ! |
| beyond room ! most smc�e:
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| --------------�----- | entrins rnntained in this re�crt are intpndpJ fvr !
i 2�'S \ ions � evaluations ma�e herin re�`resent ''MOST |
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re1--)resentation as to the conditions nutsid the \
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HIIV3H JO 3AOO V HIEINaJONAM
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: �/ y CURRENT INSTALLER'S LICENSE#
LOCATION: J'7 3 Pr1Ae,1 � '� ✓� �
S
LICENSED INSTALLER:
SIGNATURE: » TELEPHONE# y%j`'
CHECK ONE: /
REPAIR: NEW CONSTRUCTION:
�z-
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As -Built? Yes _ No
Floor Plans? Yes No���
Date:
Approval
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,
PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, INIC. -
206 ANDOVER STREET, SUITE 11
ANDOVER, MA 01810 '
(978) 475-4370 APR
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address:
Address of Owner (if different):
Name of Inspector:
Company Name, Address, Phone #
CERTIFICATION STATEMENT
173 Bridges Lane, North Andover, MA 01845
40 Apple Ridge Road, Danbury, CT
Peter F. Reilly
(I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
F.P. Reilly & Sons, 206 Andover St., Suite 11
Andover, MA 01810 (978) 475-1237 / (978) 475-4370
I certify that I have personally inspected the sewage disposal system at this address and that the
information is true, accurate and complete as of the time of inspection. The inspection was performed
based on my training and experience in the proper function and maintenance of on-site sewage disposal
systems. The system:
✓ Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: March 25, 1998
Peter F. Reilly
The system inspector shall submit a copy of this inspection report to the approving authority within thirty
(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the regional office of the
Department of Environmental Protection. The original should be sent to the system owner and copies sent
to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or D
✓ 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.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined",
explain why not►
N 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.
N Sewage backup or breakout or static high water level observed in the distribution box is due to broken or
obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if
(with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
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 the public health, safety and environment.
1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT
THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A 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.
N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well.
N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a
private water supply well, unless a water well water analysis for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance N/A
(approximation not valid).
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
D. SYSTEM FAILS:
N/A 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.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool.
N 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 <6" below invert or available volume <% day flow.
N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a 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 I of a private water supply 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. 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.
E. LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above.
N/A The design flow of system is 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:
N The system is within 400 feet of a surface drinking water supply
N The system is within 200 feet of a tributary to a surface drinking water supply
N The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone II
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 DEP for
further information.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
Check if the following have been done:
✓ Pumping information was requested of the owner, occupant and Board of Health.
✓ 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 system recently
or as part of this inspection.
✓ As built plans have been obtained and examined. Note they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage backup.
✓ The system does not receive non -sanitary or industrial waste flow.
✓ The site was inspected for signs of breakout.
✓ All system components, excluding the SAS, have been located on the site.
✓ The septic tank manholes were uncovered, opened and the interior of the septic tank was inspected for
condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of
SCUM.
✓ The facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of SSDS.
The size and location of the SAS on the site has been determined based on:
✓ Existing information (Example: Plan at BOH).
N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable [15.302(3)(b)].
PART C - SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow (gpd/bedroom for SAS):
Number of bedrooms:
Current residents:
Garbage grinder:
Laundry connected to system:
Seasonal use:
Water meter readings, if available:
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
Design Flow:
Grease trap present:
Industrial waste holding tank
Non -sanitary waste discharged the Title 5 system
Water meter readings, if available:
Last date of occupancy:
OTHER:
Describe:
Last date of occupancy:
440 gallons (1 10 gpd/bedroom)
4
0
not known
yes
no
not known
not known
not known
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: NOT KNOWN
System pumped as part of inspection: no
if yes, volume pumped: N/A gallons
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no - if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Original system installed in 1985 when house was constructed
Sewage odors detected when arriving at the site NO
BUILDING SEWER: (locate on site plan)
Depth below grade: 2" - 4"
material of construction: ✓ cast iron 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 2" - 4"
material of construction: ✓ concrete metal FRP other (explain)
Dimensions: rectangular - 1,500 gallons
N/A sludge depth
N/A distance from top of sludge to bottom of outlet tee or baffle
N/A scum thickness
N/A distance from top of scum to top of outlet tee or baffle
N/A 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, recommendations for repairs, etc.)
Tank was replaced just prior to inspection.
3 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions:
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation
to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
N/A 4
TIGHT OR HOLDING TANK: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Capacity: N/A gallons per day
Design Flow: N/A gallons per day
Alarm level: N/A Alarm in working order N/A
Date of previous pumping: N/A
Comments: (condition of inlet tee, condition of alarm and float switches, etc.) `
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,
recommendation for repairs, etc.)
The d -box was level and there was no liquid above the outlet invert on the three lines. Three lines were not accepting
effluent equally, however. One line accepted no liquid, one accepted slowly and the other accepted more rapidly.
PUMP CHAMBER: N/A (locate on site plan)
N/A Pumps in working order (yes or no)
N/A Alarms in working order (yes or no)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for
maintenance or repairs, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
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: not applicable
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
alternative system (name of technology)
three shallow pits per "as built" plan
N/A
N/A
N/A
N/A
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations
for maintenance, repairs, etc.)
Soils over leaching area were good, no evidence of breakout.
CESSPOOLS: N/A (locate on site plan)
number and configuration
N/A
depth -top of liquid to inlet invert
N/A
depth of solids layer
N/A
depth of scum layer
N/A
dimensions of cesspool
N/A
materials of construction
N/A
indication of groundwater inflow (cesspool
must be pumped as part of inspection)
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations
for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
materials of construction
dimensions
depth of solids
N/A
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations
for maintenance or repairs, etc.)
not applicable
I
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate where public water system enters house
locate all wells within 100' N/A
1 - Sfori es
4" Bui/Q%in,
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SEPTIC TANK TIES: A to Inlet (1) 26'6" B to Inlet 15'0"
A to Center (C) 22'6" B to Center 17'0"
A to Outlet (0) 19'0" B to Outlet 26'0"
D -BOX TIES: A to Box 27'7" B to Box 30'8"
NOTE: The system is in the front yard. Swing ties to pits were not on
11as built" plan. Locations of pits are approximate.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 173 Bridges Lane, North Andover, MA
Owner's Name: HFS Mobility Services, Inc.
Date of Inspection: 3/25/98
DEPTH TO GROUNDWATER
Depth to Groundwater >2' (below bottom of SAS)
Indicate all methods used to determine High Groundwater Elevation:
Y Obtained from Design Plans on record (1985 plan)
Y Observation of Site (abutting property, observation hole, basement sump, etc.)
Y Determined from local conditions
N Check with Local BOH
N Check FEMA Maps
N Check pumping records
Y Check local excavators, installers
N Use USGS Data
Describe in words how High Groundwater Elevation was established:
There was no groundwater in the hole during the excavation for the replacement
septic tank. The 1985 design plan indicated no groundwater found during deep hole
testing. Grade sightings on the site and the surrounding area indicated no
groundwater near the bottom of the SAS.
DISCLAIMER
This passing septic inspection under Massachusetts Title V in no way
guarantees the septic system. The inspection is a "snapshot in time" and
does not constitute a complete assessment of the quality or potential
longevity of the septic system. The pass/fail criteria are specific and
outlined in detail in this report. Under the limited criteria of a Title V
inspection, it is impossible to determine how long any septic system will
last. The inspector made a diligent effort to certify the septic system based
on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of
determining the high groundwater elevation. This inspector is not a
certified soil evaluator and is therefore not qualified under Title V to
determine or establish the high groundwater elevation. The method used
to estimate the high groundwater for this inspection was based on the
methods of observation described on the previous page. Groundwater
levels can vary greatly from season to season, year to year and soil
evaluation is considered the most reliable method of groundwater
determination under Title V.
ilrA
Peter F. Reilly
Inspector
March 25, 1998
/BoL of Health
North *Anc O_V! ZHaas.
s•
SEPTIC SZSTEH
INMILATICK CMrK LIST
DI SAPED
eaepnst
LOT
X A _AT ICN OK FAIL
q-5 C�G/)k/ I I u=rn 10 Wj
1.
Distance Tos
CJS
a. Wetlands
b. Drains
C.. Well 64Z2�>
2.
Water Line Location 'J
3.
No PPC Pipe q-6 e,S
Septic Tank
a. Tees -_Length do To Clean Out.Covers
b. Cement Pipe to Tank- On Both Sides of Tank
5.
Distribution Box
a. Covers & Box - No Cracks
b. All Lines - Flo Amg Equal Amounts
c. No Back Flow
6.
Leach Field or Trench
a.. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
7.
Leach Pits
a. Dinansions
b. Stone Depth
c. Splash Pads �-
d. Tees
e. Car,ant Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8.
No Garbage Disposal
9.
Anal Grading Inspection
10.
Barricading Covered System
11.
As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard_to Perc Test
d. Elevations
e. Water Table "
TO:
NORTH ANDOVER, MASS
�'7�-f^ 3 19 PS'
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
��
T %3&
1"6 G .szS c l.!-
North Andover, Mass.
SITE LOCATION
The grades and construction are as specified
in my plans and specifications dated
cOM&
Cc
c��
7-
I
2
p
e, Y
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: _ I CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTALLER:
SIGNATURE: AW TELEPHONE#S_
CHECK ONE:
REPAIR: _ NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
--f'o--undation As -Built?
Administrative Use Only
Yes ✓ No
Yes
- No
door Plans? Yes No
Approval f- Date:
Ge- 4S`N
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SUBSURFACE DIVOSAL DESIGN CHBCK LIST
0, FC)K J LOT
APPROOED DATE -1122-5 //y�
Provided:
Title V FAIL 09
DISAPPROVED DATE
Reasons: —�
61 Bpxc�
or, 'TO 155v5 JJ
Reg 2.5 1 1 I_The submitted plan mist s
Reg. 6
Reg 10.2
Reg 10.4
a) the lot to be served -at D� �C)T (S S
b location and log deep o
c location and results pe
d design calculations & c ` `� tdt� 2 ng area .
e). location and dimensions
f) existing and proposed c c� +
.g) location any wet areas ���'o a, � 10 (55,-- M or
disclaimer -check wetlan
h) surface and subsurface
system or disclaimer
i) location arty drainage ea sal
system or disclaimer -Planning Board files
;3) known sources of water supply within 2001 of sewage disposal e .
system or disclaimer
;k) location of any proposed well to serve lot -1001 from leaching facility
;1) location of dater lines on property -10! from leaching facility
;m) location of benchmark
n) driveways
o) garbage disposals
p) no PVC to be used in construction
,q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and.
other elevations
;r) maximum ground water elevation in area L3wage disposal system
;s) plan mast be prepared by a Professional'&gineer or other
professional authorized by law to prepw.t such plans
$e tic Tanks
a) capacities -T50% of flow, water table.. U ts, depth of tees,
access, pumping
b) cleanout
c) 10, from cellar wall or inground swimning ;ool
d) 251, from subsurface drains
Distribution Boxes
a) slope greater 0.08
b) sump
Roal th
`I b -2q:
APPROVED DATE,
Provided:
Title V I FAIL i
SUBSURFACE DISPOSAL DESIGN CHECK LIST
[c .
FC) (Z' ;W C LOT 4 h
DISAPPROVED DATE
Reasons.:
Reg 2.5
Reg.6
Reg 16.2
Reg 10.4
The submitted plan must show as a minimums
a) the lot to be served -area, dimensions lot #,abutters
b location and log deep observation hoes-Astance to ties
c location and results percolation testa-o.8tance to ties
d design calculations & calculations show,3-ig required leaching area
(e) location and dimensions of system-includ'ng reserve area
f) existing and proposed contours
(g) location any wet areas within 100' o' se -?age disposal system or
disclaimer -check Wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i)location any drainage easements within 1001_ of sewage disposal
system or disclaimer -Planning Board files
(j) known sources of water supply within 2001 of sewage disposal a .
system or disclaimer
(k) location of any, proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101, from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area Em;age disposal system
(s) plan mast be prepared by a Professional tagineer or other
professional authorized by law to prepay, a such. plans
$eptic Tanks
(a) capacities -150% of flow, water table, tA ts, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimming ; ool
(d) 251 from subsurface drains
Distaribution Boxes
(a) Zope greater than 0.08
b) sump .
"SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street NO-X®C,15��! Lot No
Loc/Subdiv. Pland Owner , -�/C�C>
Investigator 'b"A�a04? Observer'L--
SOIL PROFILE DATES
l Aaev 2. El ev 3. Elev 4. Elev
0 iia
1
2
3
75tl"�
4�
5
6
7
8
Benchmark
Elevation
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Location
Datum
PERCO TION TESTS
Iii I 11?A gn I Alq'i 12'-3
0
1
2
3
4
5
6
7
8
9
10
Tres pt
q sTest
Pit Number
�. �
Q
3
4
Start Saturation
: A0
:Ott
Soak -Minutes
Q7
Start e
1�
Drop of 3" -Time
3
1cV `,01
DroD of 6" -Time
M ms-lst 3" drop
it
-
Mins.2nd " DropLP
Percolation
t NORTH 1
F P
t •
SSACHUSE�I(°�
Town of North Andover, Massachusetts
BOARD OF HEALTH
DISPOSAL WORKS CONSTRUCTION PERMIT
Form No. 3
14 19 , a
Applicant /1:r-/`�' 15! Y 7 S–I J 3 7
NAME ADDRESS TELEPHONE
Site Location 173 911"" /-C:)-4�5
Permission is hereby granted to Construct ( ) or Repair (X) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
If
Fee
v
CHAIRMAN, BOARD OF HEALTH
D.W.C. No. % 9�