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Miscellaneous - 173 INGALLS STREET 4/30/2018 (2)
L i I � MAP # /0 5 ID LOT # 24 PARCEL # STREETc5r/— .. . .... . ...... CONSTCONSTRUCTION APPROYAL RUCT . ....... - ....... ............. . .. . .... . .... HAS PLAN REVIEW FEE BEEN PAID? ES M¢J9 PLAN APPROVAL: DATE �91��__�__ APP. BY 0. DESIGNER: PLAN DAT CONDITIONS 4 q3 - 9 - - ------ ---------- WATER SUPPLY: TOWN WELL WELL PERMIT. DRILLER .......... ............. WELL TESTS: CHEMICAL DATE APPROVED A0 BACTERIA I DATE APPROVED..j/ BACTERIA II DATE APPROVED COMMENTS: FORM U APPROVAL: ✓ APPROVAL TO S DATE ISSUED BY CONDITIONS: !rn, FINAL APPROVAL: ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL Yelflubo SEPTIC SYSTEM CONSTRUCTION APPROVAL Nd— OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATEBy:ow ........... . ........... ,w A IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW CONDITIONS OF APPROVAL (FROM FORM U) ISSUANCE OF DWC PERMIT DWC PERMIT NO. - 16 f� BEGIN INSPECTION ds>o: EXCAVATION INSPECTION: . ....... . .. . ................. . ... . ..... ............. . ....... ........ . . .. ... .. . ........... ..... .... ... . ....... .... .. ....... PASSED"/ BY YES NO NEW REPAIR YES (:25)- V* YES NO YES NO CONSTRUCTION INSPECTION: NEEUCI)i I" f 60K%.- - 014- w /&I Ak::6z Commonwealth of Massachusetts �viv5® W City/Town of NORTH ANDOVER �p11 a System Pumping Record ppb PNao Form 4 oo v p p�MEN� G^N& V DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. / _ h Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. Facility Information 1. System Location: 173 INGLALLS ST Address NORTH ANDOVER _ _MA City/Town State 2. System Owner: MARK GUARINI Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3/6/17 Date State Telephone Number 2. Quantity Pumped: 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ "iqo 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II Name S SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD _. 01 Zip Code Zip Code 1500 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes [] No H79 406 Vehicle License Number yN,.�t 3/6/17 Signature of Hauler Date Signature of Receiving Facility (or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of NORTH ANDOVER a ° System Pumping Record Form 4 �M Sye y`ev DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. VQ 2 RECEIVED System Location: JUN G8 2015 173 INGALL ROAD Address NORTH ANDOVER MA HEALTH 01845MENT City/Town State Zip Code System Owner: MARK GUARINI Name Address (if different from location) City/Town State Telephone Number B. Pumping Record 1. Date of Pumping 5/29/15 2. Quantity Pumped: Date 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II Name X SEPTIC & DRAIN Company 7. Location where contents were disposed: IPSWICH Zip Code 1500 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 5/29/15 Signature Date Signature of'Receiving Facility (or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record • Page 1 of 1 TRANSPIISSION VERIFICATION REPORT DATE, TIP -.9E 07/10 09:40 FAX NO. ;'N"ME 819782586136 IiURATION 00:02:21 PAGE (S} 15 RESULT OK 1,.90DE STANDARIi Wrth_ARd. er_fleulth Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01045 978.688.9540 - Phone 978.688.8476 ® Fax healthdept@jownofno!rtkandover.com - [-mail www.towaoertNndover.cam - Website TIME 07110/2007 09:43 N04E HEALTH FAX 9786882476 TEL 9786888476 SER.# 000B4J120960 Page _Z of ca` tTy:e �ee•ry®p A TO: DATE: , COMPANY: FROM: Pamela DeileChiaie, Health Department Assistant Phone: 9Jl Co RE: Fox: We are sending yor c G Copy of letter D Plans 0 Other (f1// in below, These are transmitted as checked below: i Dmve,A! L7fw4Pv&©Rama attar ®ArR' Dfnr/Peuwardca►rr�i o- L7AsR ad Py i0/ North Andover Health Denartment 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 — Fax healthdept(a)-townofnorthandover.com - E-mail www.townofnorthandover.com - Website Letter ®f Transmittal Page Z_ of / 6--� I o•,�t�e° ,6 'ti 0? � ~',' •� �, t6 OOH ,L At T0: � DATE: COMPANY: FROM: Pamela DelleChiaie, Health Department Assistant Phone: / / (J• ��� ll� /�� RE: �/� li19UO Fax: SIGNED: • (ill We are sending you. O Copy of Letter O Plans O Other f fi// in below) These are transmitted as checked below: ➢ O*pvvay&a *Ow"' ➢ afarAAwvyd ➢ L7Rwm6u* q* for ➢ L7*RaFAZ ed ➢ alorRe&*waaalaar v# opo vHi ➢ L7*R th a/ ➢ OForymri& ➢ L7&A7 't qpa sfar&t. REMARKS: 0/ , COPY TO: COPY TO: SIGNED: COPY TO: North Andover Board of Assessors Public Access Page 1 of 1 ,AORry 'Fovvrn of ATorth Aodo�ver, B_oavd; of Assessors.. i"i ��'•�_ Property Tncwus Return to the Horne page click on logo L4 Record Card Parcel ID: 210/105.D-0083-0000.0 Community: North Andover New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales PHOTO Location: 173 INGALLS STREET Owner Name: GUARINI,MARIA L Owner Address: 173 INGALLS STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 5 - 5 Land Area: 1.18 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 2464 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 547,800 496,800 Building Value: 338,600 313,900 Land Value: 209,200 182,900 Market Land Value: 209,200 Chapter Land Value: LATESTSALE Sale Price: 500,000 Sale Date: 10/24/2002 Arms Length Sale Code: Y -YES -VALID Grantor: HARDING, OLIVIA S Cert Doc: Book: 7199 Page: 89 http://csc-ma.us/NandoverPubAcc/jsp/Home jsp?Page=3&Linkld=990685 7/10/2007 In co "rl)l �A IABr4AEG+k Q -ai A Yl S U7 co LU LLI LU z cn COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _173 Ingalls Street _North Andover_ Owner's Name: _Saina'h Rahardja _ Owner's Address: 173 Ingalls Street North Andover, Ma. 01845_ Date of Inspection. 6/22/2001_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-0786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper fimction and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F Inspector's Signature: Date: _6/22/2001 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. 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: _173 Ingalls Street _North Andover— Owner: Rahardja Date of Inspection: 6/22/2001 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _173 Ingalls Street _North Andover— Owner: Rahardja Date of Inspection: 6/22/2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _173 Ingalls Street _North Andover— Owner: Rahardja Date of inspection: _6/22/2001_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. No Any portion of a cesspool or privy is within 50 feet of a private water supply well. No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either `yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _173 Ingalls Street _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? _Yes _ Has the system received normal flows in the previous two week period ? _No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Yes_ _ Existing information. 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _1 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): _ Seasonal use: (yes or no): No_ Water meter readings: _On well water_ Sump pump (yes or no): _No_ Last date of occupancy: — Current-C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): Rod Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped 1996, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: _Inspect tank & tees & baffle TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: 11 Years old. 10/29/19" . As built plan._ 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: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ BUILDING SEWER (locate on site plan) X Depth below grade: 18" Materials of construction: _cast iron _X_40 PVC _other (explain): Distance from private water supply well or suction line: _> 100' Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall to tank. 3" PVC in house. No leaks. _ SEPTIC TANK: X locate on site plan) Depth below grade: 6"_ Material of construction: —X—concrete metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth 6" Distance from top of sludge to bottom of outlet tee or baffle: 21" Scum thickness: 6" 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: _15" How were dimensions determined: _Subtract scum & sludge depth to tee length. _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _Pumped septic tank Inlet tee ok. Outlet bathe ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: (locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street_ North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ TIGHT or HOLDING TANK: T (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: allons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -Boz level & distribution equal. Evidence of carryover, pumped d -box to clean. No evidence of leakage. _ PUMP CHAMBER: (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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001 SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _X_ leaching trenches, number, length: _2 trenches 45.5' long_ 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 oL Vegetation oL No sign of ponding to surface. — CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Paige 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A to 1 = 2012" Ato2=28'2" A to D -Boa = 2815" Bto1=34' Bto2=25'7" B to D -Boz = 4712" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street _North Andover_ Owner: Rahardja Date of Inspection: 6/22/2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4 feet Please indicate (check) all methods used to determine the high ground water elevation: X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _8/15/1990_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per design pian _ BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 173 Ingalls Street, North Andover Owner: Rahardja Date of Inspection: 6/22/2001 Tel: (978) 475-4786 Fax: (978) 475-5451 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. A44'9�� Neil J. Bateson Bateson Enterprises, Inc. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _173 Ingalls Street_ _North Andover_ Owner's Name: _Sainah Rahardja _ Owner's Address: _173 Ingalls Street_ _North Andover, Ma. 01845_ Date of Inspection: _6/22/2001_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ JUN 2 7 2001 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: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fi Inspector's Signature: Date: _6/22/2001 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. 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: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: 6/22/2001 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: 6/22/2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _173 Ingalls Street _North Andover— Owner: Rahardja Date of Inspection: 6/22/2001_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or `%o" to each of the following for all inspections: Yes No No— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. —No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or `no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No _Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? _Yes _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ? Yes_ _ Was the site inspected for signs of break out ? _Yes_ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes_ _ Existing information. 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _1 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): _ Seasonal use: (yes or no): —No _ Water meter readings: _On well water_ Sump pump (yes or no): —NO-- Last No_Last date of occupancy: _Current COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap pi esent (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): J GENERAL INFORMATION Pumping Records Source of information: _Pumped 1996, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: _Inspect tank & tees & baffle TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval _ Other (describe): Approximate age of all components, date installed (if known) and source of information: _11 Years old. 10/29/1990 . As built plan._ 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: _173 Ingalls Street _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ BUILDING SEWER (locate on site plan) X Depth below grade: 18" Materials of construction: _cast iron _X_40 PVC _other (explain): Distance from private water supply well or suction line: _> 100' Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall to tank. 3" PVC in house. No leaks. _ SEPTIC TANK: X locate on site plan) Depth below grade: —6" — Material of construction: —X—concrete _metal _fiberglass ___polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth 6" Distance from top of sludge to bottom of outlet tee or baffle: 21" Scum thickness: 6" 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: _15" How were dimensions determined: Subtract scum & sludge depth to tee length. _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _Pumped septic tank Inlet tee ok. Outlet baffle ok. Outlet tee ok Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street_ North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -Box level & distribution equal. Evidence of carryover, pumped d -box to clean. No evidence of leakage. _ PUMP CHAMBER: (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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: 6/22/2001 SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _X_ leaching trenches, number, length: _2 trenches 45.5' long_ 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 ok. Vegetation ok. No sign of ponding to surface. _ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street_ _North Andover— Owner: Rahardja Date of Inspection: _6/22/2001_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A to 1= 20'2" Ato2=28'2" A to D -Box = 28'5" Bto1=34' Bto2=25'7" B to D -Box = 4712" O1 --- -- -- Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _173 Ingalls Street_ _North Andover_ Owner: �Rahardja Date of Inspection: 6/22/2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4 feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _8/15/1990_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: _As per design plan _ F Tel: (978) 475-4786 " Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 173 Ingalls Street, North Andover Owner: Rahardja Date of Inspection: 6/22/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. o � Neil J. Bateson Bateson Enterprises, Inc. e r- N JI '' " L) - ek ir x- s r b3 r l F l (,•(/1 L /n' v r i J z 3 v 41 a I ! d•: a w r' �t AS ,. OF s u LOCATED . AS PRE d' 1. ' V�.I AL ' DATE: n SCALE: <r ,. J-0 T' i p .k P, 4: , BUIL COP— Z3.7 Y`• -'V V tom' �� �• —I, Z73 �o �_XlS r F � 15 r'A . - • �e _<3 V�•4 � fI 6 - N AXI g`I"°'z~ ' `;� I ��c• '.y-� 7,v I etc, ��71G,��t� Y a 4AVIS IQ 91"55�FE�Z) y F Al" lzy 4. A & S�; - T�)E_ AS go) c.7--6.ocAilolu,9 k Al +s x S'ie�C� AN -As, WEDS 4 of F, Lf—:: k3n`4 3f—:;. > Y ,•'r STM. x ��. � ;�: k = �o�-Tf•t- �1�.tDo�r �., C DISPOSAL Zom'iE M Ero�1�7s l ` �Y �. �r r r I•� � � �sr, t' -NS 'C.1 r 9�9CC o� ROBERT C vp DALEY CIVIL vi \� } h AL ^ x r yt i sk f .. 1A RIMA K ENGINEERING: SERVECES, INC. 'R ESSIONA ENGINEERS • LAND SURVEYORS • PLANNERS RK ;STREET c ;• "DOVE& MASSACHUSETTS 01810 � . TEL (617) 473 -MM. 97}5721., a W��sHUAWES 0 AS �UI'LT �GJU�-SUrL��E, j�ISPO 5Y'ST EM ' L. i I►J Q2 -r VA FRAGtLINAS r� ,a .p No. `2738 p '? �Q/ST&� k`�'� � �JG4 LE I " = 4—d DATEi I 7Z/-7/81 NA ` . FRAN1� C.. C7ELiNAS � ASSvGIt�.'f'E`j �N61NEE�g ARC-�-IITEG7- TO: Qve AkiDovc- BOA i?D d-- 0 EA L -r ►-1 FROM: PiA IV e- C • Cif NaS 3 ASSoc..- -X,-JL - NORTH ANDOVER, MASS. -7 19 6" BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have inspected the construction materials of said disposal system z�t A JJe=>A 1-5 ST• Site Location North Andover, M.A. The grades and construction materials are as -specified in my plans and specifications dated _ 1981 and D FL - -7 19!K I C —1) U- K �, v Req. Prof. Engineer/Reg. Sanitarian p W �vsM �/eu I WV PIPE OUT OF NSE I' L 1 } f Pl V f7l�E INTO T�L►L I�, 1 3 It►`iP►PEDUTOFrADl1� I I d�'"i�� CJU15"SV{.r--Aac.EDI P05AL... i N V_ PI PE I t4TO V BOX I.A. 5 LNV. DI DE ��T C?.FlsnX I @i .4.o SY45T EM UNIV ENID OE 4-; PE 118. G)8 ` � a ss o Q T �--� �. t•� c� � v FRANK �yc P7 GZ ,r\" NG%2,73P��, .c STS NAL F*Q4,K C GC7Et_iNAS,� ASSVGI�-7-E�j ` �NC�INEE25�. ARL.1,-1tTEGT'� • g Sl ,d.N DGr/�.l"2 �3Z' f� o. AN Ql��lE-�' . TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 2 Is k, vvwt k C-13 71;�Ta-S TIO (example: left front of house) F("� VALL OF PUMPING: ,-1���,1 QUANTITY PUMPED ( ' GALLONS YES CESSPOOL: NO cJ YES SE IC TANK: NO NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: EMERGENCY i6?v i� ®®F Q H D0\1 R/ BOAR0 OF �F JUN 2 T 2041 FULL TO COVER BAFFLES IN PLACE _ LEACHFIELD RUNBACK -° FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: to�7.1 • ,S 6 , NQF�3R ` 0 `M1' GALLO .464 AL IN ?� sl Zt O �v0 w. � � o � � h Vim••., a � ' � �' � -' of , `� �' W h .0l nINQo qL lk UJ j 0 W � .,� taW� Aj r d cz e —ooll r LVJ N 0 N �l k j I t ✓ FAL I �I l,oT Jo`T 2 ,Q i14j6A45 Na►STN /JtiC�U�I>, M,4, • Psi Cgti A Q (.y Ta C-R SOPPLI -- Q F6)wt-j--SWELL- A�' oyCDIYJrC `s 23 5EPT!C syS TEA -1 CAJ 4P,;21 ovt�v D r , oNPITIo�JS : DIS,4PPRUVEp D/�if; R�4SoNS s IJa►rkl �(G,n 0%T�d 3-16 -$ 7 PLO(-- '5f rcc SYSTEM i�S►Al1�Tio�U �U�Tcc�1J 1����.c ► roti 1=rNAL IlJ,Sp� i IonJ 4 PPROJED 94rc D►S�' pr'�ov�l� D,4 ►C Fk4 L A PPi OVA L DATE 4 a 045S E] F4 /�Pl�rzavrn�G �1 � Trto r� i � y VA i �d�^of Health rth Andqve!Kj?laas• BKMC SnTEM INSTALLAT` CK CE30K LIST LOT DI PPROM AVATICK OK FAIL— 1- Rea t OK .f . .;.•.- yip 1. Distance Tot r� r' a. Wetlands be Drains L �~. 2. Water Line Locationf t 3�No PVC Pipe r ' tic T a. -._Tees - -_Length do To Clean 0ut Gowers PV M b. Cement Pipe to Tank Oa Both Sides of Tank •'' ° ` + 5. Distribution Boa a. b. Covers All Lines owing E6alBAmoimts �A-s' -2-L c. No Back Flogee 69, `Leach Field or Trench f a: Dimensions be- Stone Depth f . .3 • '� nc. Capped Fids' f =jt'Y. *� d. °Clean Double, Washed Stone's 7. Leach Pits a. Din:ensions be'' Stone D - c. Sola ads d. T e. ezaent Pipe to Pit - Both Sides - f . Clean Double Washed Stone E Be No Garbage Disposal ✓ ��1�3 `�Z /�� (, 9- Final Grading Inspection P 00 � 2�l 10• Barricading Covered System ]1. As Built Submitted_. i ' a. hot Location -e�- i b. Dimensions of System c. Location -4th Regard -to Pere Test d. Elevations W e: Water Table i. r 0 B^sard of I' " h i t SIIB. URFACE DISPOSAL DESIGN CRHCK LIST LOT .._..� APPROM DATE Provideds DISAPPROVED DATB- Reasons: Ap/ i F �- Reg 2.5 The submitted plan must show as a minimums the lot to be served-area,dimensions lot`,abutters location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties 4 sign calculations & calculations showing required leaching area location and dimensions of system -including reserve area f xisting and proposed contours g) location any wet areas Athin 1001 of sewage disposal system or wetlands mapping 4disclaimr-check h) : surface and subsurface drains within 1001 of sewage disposal vstem or disclaimer (i) location any drainage easements within 1001 of sevvge disposal system or disclaiarar-Planning Board files j) sources of water supply within 2001 of sewage disposal e system or disclaimer ation of any proposed well to serve lot -1001 from leaching facility cation of water lines on property -101 from leaching facility location of benchmark (n)-' driveways Ugarbage disposals 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 /,--no other elevations madmam ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6Septic Tanks 'vll(a) capac t es- 50% of flow, water table, tees, depth of tees, access, pumping ' (b) cleanout c') 101 from cellar wall or inground sig pool - / (d) 251 from subsurface drains Reg 1.0.2Distribution Boxes 1 //6 slope greater than 0.08 Reg 10.4 ✓ b) sump /A%Subs rrface Design Check List +7 -age ' F= OK ' { Leaching Pits Leaching pits are pref d where the installation is possible Reg 11.2 11 ' .4 a) calculations of hing area -m mi 500 sq ft - b) spacing 11.10 1 11.11 c surface draC age 2% d� cover�miterial a s Reg 15.1 15.4 15.8 3.7 e) IIa2-+x4a splash pad f) te(e at elbow g)/no bends in pipe from d -box to pipe eaching Fields no greater than 20 minutes/inch -minimam 900 sq ft Sac notrcction of field surface drainage 2 % e) 201 from cellar wall or inground swlmndng pool Reg 14.1 14.3 14.4 14.6 l 14.7 L eachin roaches -- a) c�a c� a ons o ching area-rdn 500 sq ft b spacing -4 ft 6 ft with reserve between c)' disio d) cons tion le) sto 14.10 f) -� face drainage 2% i Downhill �Sl.o. 2e a) Slope Y/x = (to be shown) b) y/x X 150 = (to be shown) /4i Reg 9.1 9.6 Emx a) approval 1b) stand-by power = a m E 14 J1 a Ap. y jirte.,' mg r. m 60P, •.c�<;4� Pw_ d US it-, IA �mxx -V 4V Af 0 7- A ie 4w- lk rOMI-5, "w L.4 N7, . �-55 . Yr ��"W FZ "k '"MIA Y! T w , se� y�k rz, �-�,aasP pv� KX4c T* -V TA 7&t: F,T? Z. U? T 7 m tj A, VL� ?L.&j M now E -:As, �wi WT. tel,aa 1v C I ?I I w 71 dOr 14&�Solc: �rl A 'AIVU 7*,,qqr, rr cbas Kk Ak�, A TotH*r- Z. &/;,VS Town of North Andover, Massachusetts Form No. 3 E NORTH BOARD OF HEALTH O tteo Vag tip 9 f 9 DISPOSAL WORKS CONSTRUCTION PERMIT 9SSACHUSEt Applicant J- E-1 i:z- 6-4k) NAME ADDRESS TELEPHONE r Site Location to -r 7� —A /(VU/4665 5) - Permission is hereby granted to Construct q4 or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Q26 Fee cTiAIRMAN, BOARD,9F HEALTH D.W.C. No, (5 -5 Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH //%f r�,��/N/ Q O A g1 7 4 AT APPLICATION FOR SITE TESTING/INSPECTION ��SSACHUS�� Applicant%i��! NAME ADDRESS TELEPHONE Site Location Engineer�ii'/. _'00, "-r"2/'C_'i,(."y r NAME c/' ADDRESS TELEPHONE Test/Inspection Date and Time 4)J,4 f, CHAIRMAN, BOARD OF HEALTH Fee/�-/��- Test No. S.S. Permit No.=� ' D.W.C. Na -411— C.C. Date Plbg. Permit No. VZ9S .11 Department of Environmental Management/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION /�- GEOGRAPHIC DESCRIPTION Address - A /� City/Tow n/l�C�Alcle 21961etf / (reed (circle) �� L ✓ Well owne r pe (road) Address 74 NSof mi. i, n t�nthSJ circle) intersect. w/ Board of Health permit: yes no ❑ (road) WELL USE Domestic Public WELL DATA Total dept f (3 Industrial ❑ well ft. Monitoring ❑ Other Depth to bedrock_ ft. Water -bearing rock/unconsolidated material: Method drilled Date drilled Description Water -bearing zones: 1)From �To �d CASING Type � S/G��� Lengthft. Dia(.I.D.)4__in.. 2) From14,10To Length into bedrock �5ft. 3) From To Gravel pack well: dia. Protective well seal: Screen: dia. Grout -0 Other ! Slot# length —from— to PUMP TEST Static water level below land surface _ft. Date Drawdoal:;; tL_ft. after pumping—/—hr. min. at Ze�2 gpm How measured,26Z�_. Recover�ft. aIter�hr. min. 0 LOG of FORMATIONS COMMENTS Materials From Ta Driller Mass. Registration#') Firm �i�l/1�.m2�C C% Address /fc City/Town .) 1 i nature oWfflbrvising registered well driller Please print firmly RILLE COPY i ACTION -KIN(.. ENTERPRISES, INC:. 26 LIVINGSTON STREET LOWELL, IIIA 01852 TEL: (508) 452-77/50 FAX: (508) 459-0770 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F FARTA CERTIFICATION PROPERTY ADDI?ESS: 173 INGALLS STREET N. ANDOVER, ilia# 01845 DATE OF INSPECTION: 8-14-96 NAME OF INSPECTOR: FRANCIS KING JR. CERTPFICATION STATEMENT TOWN OF NORTH APlf�OVER/ BOARD OF HEALTH R MAUG 151996 ADDRESS OF OWNER: (IF DIFFERENT) 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 TI MIE, OF INSPECTION. THE INSPECTION WAS PERFORMIED BASED ON IMY TRAINING AND EXPERIENCE 1N THE PROPER FUNCTION AND MAINTENANCE OF ON -SI'Z'E SEWAGE DISPOSAL SYSTEMS. THE SYSTENI. X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING s lr-ruORIT FAILS 8 -14 - THE SYSTEM lNSPECTOR SHALL SUBIMIT A COPY OF THIS INSPECTION REPORT 10 THE APPROVING AUTHORITY WITHINTHIRTY (30) DAYS OF COMPLETING '1'17/1.5 INSPECTION. IFTHE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10.000 GPD OR GREATER, TIIE INSPECTOR AND THE SYSTEM OWNER SMALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONIMENTAL PROTECTION. THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER, IF APPLICABLE AND THE APPROVING AUTHORITY. INSPECTION- SUNINsARY• CHECK A, l7/, C, OR 1). A) SYSTElI PASSES: X 1 HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT 1'HE SYSTEM. VIOLAT'E'S ANY OF THE FAILURE CRITERIA AS DEFINED IN 310 Cl%lR 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. Il) SYSTEM CONDITIONALLY PASSES: ONE OR MORE SYSTEM COMPONENTS NEED TO BE REPLACED OR REPAIRED. THE SYSTE IM UPON COiriPLETiON OF 'llE RE PLA C'Eiv1ENT OR RE, PA IR, PASSES INSPECIION. INDICATE YES, OR NO, OR NOT DETERMINED (Y, n, OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL INSTANCES. IF "NOT DETERMINED EXPLAIN WHY NOT. THE SEPTIC TA 'K IS METAL, CRACKED, STRUCT(,'RALLY UNSOUND, SHOWS SUBSTANTIAL INFILTRATION OR EXFIL'I'RA'1'1(.)N, OR TANK FAILURE 1S 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. PAGE 1 ACTION -KING ENTERPRISES, INC. 26 LIVINGSTON STREET LOWELL, MA 01852 TEL: (508) 452-7750 FAX: (508) 459-0770 . PROPERTY ADDRESS: 173 INGALLS STREET N. ANDOVER. DTA 01845 OWNER: WALTER CASAVECCH1.11 DATE OF INSPECTION: 8-14-96 ACTION KING ENTERPRISES, INC. HAS BEEN RETAINED BY THE OWNER TO PROVIDE AN INSPEC'I'I.ON OF THE ON-SITE SEWERAGE DISPOSAL SYSTEM AS DEFINED BY 310 CMR 15.303.D.E.P. GUIDANCE INSTRUCTS THE INSPECTOR TO MAKE AN EVALUATION OF THE SYSTEMS PERFORMANCE ON THE DAY OF THE INSPECTION. THE TITLE 5 INSPECTION IS NOT DESIGNED TO PROVIDE INFORMATION TO DEMONS'I'RA'l.'E 'T'HA'I" I'HE SYS'T'EM WILL ADEQUATELY SERVE THE USE TO BE PLACED UPON IT BY THE NENV OWNER AS STA'T'ED IN 15.302. THIS ISPECTION IS NOT A WARRANTEE OR GUARANTEE OF THE SYSTENM FUTURE PERFORMANCE, AND DOES NOT EITHER EXPRESS OR I!'IPL `' IT. PAGE i -A ACTION -KING ENTERPRISES, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 173 INGALLS STREET N. ANDOVER i,1A 01845 OWNER: WALTER CASAVECCRIA DATE OF INSPECTION: 8-14-96 B) SYSTEM CONDITIONALLY PASSES (CONTINUED) NfA SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL OBSERVED IN THE DISTRIBUTION BOX IS DUE '1'O BROKEN OR OBSTRUCTED PIPE(S) OR DUE TO A BROKEN, SETTLED OR UNEVEN DISTRIBUTION BOX. THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF THE BOARD OF HEALTH). BROKEN PIPES) ARE REPLACED OBSTRUCTION 1S REMOVED DISTRIBUTION BOX IS LEVELED OR REPLACED THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR OBSTRUCTED PIPE(S). THE SYS'I'Em WILL PASS INSPECTION 1F (WITH APPROVAL OF THE BOARD OF HEALTH). BROKEN PIPE(S) ARE REPLACED OBSTRUCTION IS REMOVED C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N'IA CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE 1F THE SYSTEM 1S FAILING TO PROTECTTHE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT. 1) SYSTEM WILL PASS UNLESS BOARD OF H1:ALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING 1N A MANNER WHICH WILL PROTEC'1"1'HE PUBLIC HEALTH AND SAF.E'I'Y 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 SALTMARSH. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IF FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAF'E'TY AND THE ENVIRONMENT. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN 100 FEET TO A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN A ZONE I OF A PUBLIC WATER SUPPLY WELL. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS LESS THAN 100 FEET BUT 50 FEET OR MORE FROM A PRIVATE WATER SUPPLY WELL, UNLESS A WELL NATER ANALYSIS FOR COLIFORM BACTERIA AND VOLA TILE ORGANIC COMPOUNDS IND] CATES THAT THE WELL 1S FREE; FROM POLLUTION FROM THAT FACILITY AND TILE PRESENCE OF An'1MONIA NITROGEN AND NITRATE NITROGEN IS EQUA 11, TO OR LESS THE 5PPNI PAGE 2 ACTION -KING ENTERPRISES. INC. D) SYSTEM FAILS: N/A I HAVE DETERMINED THAT THE SYSTEM VIOLATES ONE OR MORE OF THE FOLLOWING FAILURE CRITERIA AS DEFINED IN 310 CNIR 15.303. THE BASIS FOR THIS DE I ERMINATiON a»•• rr•rr a� r rr• � r�rr nry rr• n rwr �*ro IS IDENTIFIED BELviTr'. Thr. BOARD OF HEALTH SHOULD BE CONTACTED TO DETERIIIiec WHAT WILL BE NECESSARYTO CORRECTTHE F:41LUN. BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENTD E TO A:,"-,' OVERLOADED OR CLOGGED SAS OR CESSPOOL. DISCHARGE OR PONDING OF' N;F'F'LUEN'I"1'O'I'HN; SURFACE OF" THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE: INVERT D-UlTO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. LIQUID DEPTH IN CESSPOOL IS LESS THAN 6" BELOW INVERT OK AVAILABLE VOLUME IS LESS TIIAN V2 D.kY FLOW. REQUIRED PUMPING MORE TT"T:!N 4'TRIES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE(S). NUMBER OF" I'MIES PUMPED ANY PORTION OF THE SOIL ABSORPTION SYSTEM, CESSPOOL OR PRIVY IS BELOW THE HIGH GI?OUNDWA'TER ELEVATION4. ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEE T OF ASI RFAC—E WATER SUPPLY OK'TRIBU'TARY TOA SURFACE WATER SUPPLY. ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. ANY PORTION OF A CESSPOOL OR PRIVY IS NVITHIN450 FEET OF A PF IA. A —11:. WATER SUPPLY VV'ELL. ANY P0RTI 0N OF A CESSPOOL OK PRIVY IS LESSTHA N 100 FE'E'L' BlJ'I' GKEATF.K THAN 50 FEET FROM A PRIVATE WATER SUPPLY WELL WITH NO AC_.CEl"I'AB'LE WATER QUALITYANALYSIS. IF THE WELL HAS BEEN ANALYZED TO :BE ACCEPTABLE, ATTACH COPY OF WELL WATER ANALYSIS FOR COLIFOPLAI BAC'T'ERIA, VOLA'1'LLE OK(.:ANIC' COii%IPO(.iNI)S,AMM.ONIA NI.'I'KO(;h:N :ANI) NITRATE NITROGEN. E) LARGE SYS T Eire FA ILS z THE FOLLOWING CRITERIA APPLY 'TO LARGE SYSTEMS IN ADDITION TO THE CRITERLL AB OVE. N/A THE DESIGN FLOW OFSYSTEM IS 10,000 GPD OR GREATER (LARGE S1`S'1'EM) ANI) THE SYSTEM IS A SIGNIFICANT 'THREAT TO PUBLIC HEALTH AND SAFETY AND THE ENVIRON:INIENT.BECAUSE ONE OR :MORE OF T14E FOLLOWING CONDITIONS EXIST: THE SYS'11M IS WITHIN 400 FEETOFA SURFACE DRINKING WA'TE'R SUPPLY THE SYSTEM IS WITHIN 200 FEET OF A TRIBUTARY TO A SURFACE DRINKING WATER SUPPLY. THE SI"SIEiM IS LOCATED ENA NITROGENS SENSITIVE AREA (INTERIirIVIELLHEAD PRO'TECT'ION AREA (WPA) ORA MAPPED GONE 1.1 OFA PUBLIC WA'I'F;K sUPPI.,Y WELL. THE OWNER OR OPERATOR OF ANY SUCHSYSTEINI SHALL BRING TIIE SYSTEii AND FACILFFI' INTO FULL COMPLIANCE W'IT'H THE GKOUNDW'A'I'EK 'I'KF;A'I'i11EN'l'.PROGKAM KEQUIKEMEti'TS OF 314 (.,M h 5.00 AND 6.00. PLEASE CONSULT TIIE LOCAL REGIONAL OFFICE OF THE DEP:�RTMEN'I' FCr L' 'at'T'?ER INFORMATION. PAGE 3 ACTION -KING ENTERPRISES, INC. PA R'1' B CHECKLIST PROPERTY ADDRESS: 173 INGALLS STREET N. ANDOVER, MA 01845 OWNER: WALTER CASAVECCHIA DATE OF INSPECTION: 8-14-96 CHECK IF THE FOLLOWING HAVE BEEN DONE. _X PUMPING INF ORIVIATION WAS REQUESTED OF THE OWNER, OCCUPANT, AND BOARD OF H EA LTH. X NONE OF THE SYS'TENI COMPONEN'T'S H.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. _ X AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH NIA. X THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. X THE SYS'1'ENI DOES NOT RECEIVT; NUN-SANI'1'AKY OR INI)US'I'K.IAL WASTE k'LOW. X THE SITE WAS INSPECTED FOR SIGNS OF .BREAKOUT. _X ALL SYSTEM COMPONENTS, EXCLUDING THE SOIL ABSORPTION SYSTEM., HAVE BEEN LOCATED ON THE SITE. _X THE SEPTIC TANK MANHOLES WERE UNCOVERED, OPENED, AND THE INTERIOR OF THE SEPTIC'TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEE, MATERIAL OF CONSTRUCTION, DIMENSIONS, DEPTH OF LIQUID, DEPTH OF SLUDGE, DEPRTH OF SCUM. X THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION UK APPKOZIMATED BY NON-1NTKUSIVE METHODS. _X THE FACILITY O`VNER AND OCCUPANTS, IF DIFFERENT FROM OWNERS WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUB -SURFACE DISPOSAL SYSTEM. PAGE 4 SUBSURFACE SEWAGE DISPOSAL IINSPEC.TION FOIUV"I PAKT C SYSTEM INFORMATION PROPERTY ADDRESS: 173 INGALLS STREET N. ANDOVER MA 01845 OWNER: WALTER CASAVECCHIA DATE OF INSPECTION: 5-14-46 RESIDENTIAL: DESIGN FLOW: _440 GALLONS. NUMBER OF BEDROOMS: 4 NUMBER OF CURRENT RESIDENTS: 4 GARBAGE GRINDER EVES OR NO) NO SEASONAL USE (YES OR NO) NO WATER METER READINGS, IF AVAILABLE: WELL WATER MORE THAN 100' AWAY LAST DATE OF OCCUPANCY: OCCUPIED COMMERCIAL/INDUSTRI A I : TYPE OF ESTABLISH"IMIEN T : _N/A DESIGN FLOW: GALLONS/DAY GREASE TRAP PRESENT, (YES OR NO) INDUSTRI.AL WASTE HOLDING TANK PRESENT: (YES OR NO) 1'�Ol\-JA1tITli101r YY�1J1E DI.JI.il.tRGED TO TILE TITLE 5 SYSTE.tI: GEES OR NO) WA'1'EK IVIEY'ER READINGS, I.F AVAILABLE;: LAST DAY OF OCCUPANCY: OTHER: (DESCRIBE) LAST DAY OF OCCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION. 2 YEARS (HOME OWNER) PUMPED 3 TIMES IN 6 YEARS SYS TEr'l PUMPED AS PART OF INSPECTION (YES OR NO) YES 1F YES, VOLUME PUMPED 1500 GALLONS. REASON FOR PUMPING INSPECTION TYPE OF SYSTEIM -X SEPTIC TANK/DISTKIBUTTON BOX/SOIL ABSORPTION SYSTEM SINGLE CESSPOOL OVERFLOW CESSPOOL PRIVY SHARED SYSTEM (YES OR NO) (1F YES, ATTACH PKVIOUS INSPECTION RECORDS, IF ANY) OTHER (EXPLAIN) APPROXIMATE AGE OF ALL COMPONENTS, DATE INSTALLED (IF KNOWN) AND SOURCE OF INFORMATION. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE. (YES OR NO) NO PAGE 5 ACTION -KING EN'T'ERPRISES, INC. PART C SYSTEM INFORMATION (CONTINUED) PROPER'T'Y ADDRESS' 173.11-4'G A L L SS'TRi c'I' N.ANi)O*vER, 1V1A 0'io4S OWNER: WALTER CASAVECCHIA DATE OF INSPECTION: &-14-96 SEP'T'IC 'TANK: X (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: o" MATERIAL OF CONSTRUCTION: X CONCRETE META L FRP OTHER (EXPLAIN) DIMENSIONS: 10'X 5' X 6' SLUDGE DEPTH: DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: SCUM THICKNESS: 0 DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: Y' DIS'T'ANCE FROM BOTTOM OF SCUMTO BOTTOM OF OUTLETTEE OR BAFFLE: 2' COMMENTS: (RECOMMENDATION FOR PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, DEPTH OF LIQUID LEVEL IN RELATION '1'0 OU'TLE'T' INVERT, STRUCTURAL IN'T'EGRI'T'Y, EVIDENCE OF LEAKAGE, ETC.) TANK LOOKED GOOD - WELL MAINTAINED - NO SCUM AND NO SIGNS OF PREVIOUS BACKUP. GREASE TRAP: N/A (LOCATE ON SITE PLA`) — 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:_ COMMEN'T'S: (RECOMMENDATION FOR PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, DEPTH OF LIQUID.LEVEL IN RELATION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE. ETC.) PAGE 6 ACTION -KING ENTERPRISES, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 173 INGALLS STREET N. ANDOVER. MA 01845 OWNER: WALTER CASAVECC141A DATE OF INSPECTION: 8-14-96 TIGHT OR BOLDING TANK: NIA (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: MATERIAL Off' CONSTRUCTION: CONCRETE METAL FRP OTHER (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: GALLONS/DAY ALARM LEVEL COMMENT: (CONDITION OF INLET T EE, CONDITION OF ALARNI AND FLOAT SWITCHES, ETC.) DISTRIBUTION BOX: YES (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: Q COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL, EVIDENCE OF SOLIDS CARRi' OVER, EVIDENCE OF LEAKAGE INTO OR OUT OF BOX, ETC. NO SIGNS OF PREVIOUS BACKUP PUMP CHAMBER: (LOCATE ON SITE PLAN) PUMPS 1N WORKJNG ORDER (YES OR NO) N/A COMMENTS: (NOTE CONDITION OF PUINIF CHANIBER, CONDITION OF PUMPS AND APPURTENANCES, ETC.) PAGE 7 ACTION -KING ENTERPRISES, INC. PROPERTY ADDRESS: 173 INGALLS STREET N. ANADOVER. MA 01$45 OWNER: WALTER CASAVECCHIA DATE OF INSPECTION: 5-14-50 SOIL ABSORPTION SYSTEM (SAS):_X (LOCATE ON SITE PLAN, IF POSSIBLE, EXCAVATION NOT REQUIRED, BUT MAY BE APPI? OZ II IATED BY NON-INTURSIVE ZIETHIODS). IF NOT DETERMINED TO BE PRESENT, EXPLAIN: TYPE: LEACHING PITS, NUMBER: LEACHING CHAMBER, NUMBER: LEACHING GALLERIES, NUMBER: LEACHING TRENCHES, NUMBER LENGTH: (FOUR? X 49' LEACH NG FIELDS, NUiiBEB, DINIENSIONS: OVERFLOW CESSPOOL. NUMBER: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION OF `v'EGETATION, ETC. NO SIGNS OF BREAKOUT AND VEGETATION LOOKS GOOD CESSPOOLS: /A (LOCATE ON SITE PLAN) NUMBER AND CONFIGURATION: DEPTH -TOP OF LIQUID 1-0 INLET INVEnT: DEPTH OF SOLIDS LAYER: DEPTH OF SCUM LAYER: DMIENSIONS OF CESSPOOL: MATERIALS OF CONSTRUCTION: INDICATION OF GROUNDWATER: INFLOW (CESSPOOL MUST BE PUMPED AS PART OF INSPECTION: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULICA FAILURE, LEVEL Or' PONDING, CONDITION OF VEGETATION, ETC.) PRIVY: N/A (LOCATE ON SITE PLAN) MATERIALS OFCONSTRUCTION: DIMENSIONS: DEPTH OF SOLIDS: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION OF VEGETATION, ETC.), PAGE 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) v o 83 PROPERTY ADDRESS: 173 INGALLS STREET N. ANDOVER, MA 01845 OWNER: WALTER CASAVECCHIA DATE OF INSPECTION: 8-11_ vF SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO A T LEAST T'►tr'O PERMANENT REFERENCE'S LANDMARKS OR BENC HMAIaKa COAT ALL W ELLS W ITH1N 100' I GkTTS STREET XT. AND �L 48' DEPTH TO GROUNDWATER DEPTH TO GROUNDWATER. METHOD OF DETERMINATION OR APPROXIMATION: NO VISIBLE WA T ER IN AREA - NO SUMP PUMP IN CELLAR PAGE 9 R FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the. a 1 t d 1 d fr pp scan an or an owner om comp iance Wi any app ica a requirements. 4!r"' i APPLICANT Sal n a,6 &- hand `a PHONE 2 ASSESSORS MAP NUMBER LOTNUMBER (2� 4. SUBDIVISION LOT NUMBER S'T'REET ���� STREET NUMBER / �s OFFICIAL USE ONLY �� RECOMMENDATIONS OF TOWN AGENTS ....., ............. .................... DATE APPROVED "ONADMINISTRATOR DATE REJECTED( t COIvIIVIFNIS V0_045 TOWN PLANNER CONUVIENTS FOOD INS t -,OR - 17TH J r'SEP C PECTOR - HEALTH r� CONN ENTS PUBLIC WORKS -. SEWER / WATER CONNECTIONS DRIVEWAY PERNIIT FIRE DEPARTMENT DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED— /r/// ,,/ DATE REJECTED iT ff DATE APPROVED DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE P /--e)d r v House floor plan Residence at 173 In IST Level Ltvi n9 Roam Pirntnq Room Rr=Art ST4tR5 -ifo Q bqz North Andover, MA EN VR` scale: 1/8" = 1'-0" f:d,ni i R odm v KtAchen room h 5t..toEe o� qC0 SunD&K Screene-v V08Ch -1% C��c hct;Sc STO < iR WdSTC-K f3ED Roam Lines gad V j Vv�h C irZL Notes: Footprint of house: 28 x 45'. Basement: unfinished plus 2 car garage Attic: Unfinished storage with access from 2' floor Prepared by Jon Ellertson from field measurements made August 10, 2000 and submitted by request to Susan Ford LOCATED IN NORTH ANDOVER, MASS. SCALE:1 "=40' DATE:9/26/96 :12/10/96 w Scott L. Giles R.P.L.S. LL! LU r� J NOTE: ON OCTOBER 20, 1996, 11 INCHES OF RAIN FELL IN THIS REGION. THIS AMOUNT IS NEARLY TWICE THE 6.4 INCHES FOR, A 100 YEAR EVENT IN THIS AREA. THERE WAS NO WATER OBSERVED IN THE BASEMENT, DRIVEWAY OR REAR YARD OF THIS PROPERTY. VERY TRULY YOUR SCOTT L. GILES R.P.L.S. 50 Deer Meadow Road North Andover, Mass. LOT #3 LOT #2 51,273 S.F. PLAN #8654 N. E. R. D. x LOT #1 THIS BUILDING IS NOT IN A FLOOD HAZARD ZONE PER FIRM.MAP 250098 0009 C. '1 r� a� 00 � foo, �a a"° ♦ 0+ O i \0.0. I CERTIFY THAT. THS OFFSETS OFFSETS SHOWN , ' E FOR THE USE SHOWN COMPLY OF THE BUILDING P-j-PECTOR ONLY WITH THE ZONING BYLAW OF AND SUCH USE IS F=OR THE NORTH ANDOVER IRETERMINATION OF ZONING WHEN BUILT CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. -I- October 29, 1990 Walter Casaveccia 32 Saint Ann Peabody MA 01960 Ref; Lot 2 Ingalls Road No. Andover Please be advised that the drilled well on Lot #2 Ingalls Road No. Andover was pumped for four hours at 10 gallons per minute on June 26, 1990 and water samples were taken for analysis.. The test results are attached. Thomas Bree Wilmington Pump Supply Inc. WELLS Wilmington Pump Supply, Inc. Pumps ARTESIAN Est. 1936 SALES & SERVICE EXPLORATORY Water Supply Contractors TURBINE REHABILITATION MUNICIPAL - INDUSTRIAL CENTRIFUGAL TEST WELLS P.O. Box 517 - 639 Woburn Street - Wilmington, MA 01887.0717 SUBMERSIBLE GRAVEL DEVELOPER Tel. Area Code (617) 658-9111 SEWAGE GRAVELPACKED CHEMICAL Smith Pump Co. (603) 669-9119 October 29, 1990 Walter Casaveccia 32 Saint Ann Peabody MA 01960 Ref; Lot 2 Ingalls Road No. Andover Please be advised that the drilled well on Lot #2 Ingalls Road No. Andover was pumped for four hours at 10 gallons per minute on June 26, 1990 and water samples were taken for analysis.. The test results are attached. Thomas Bree Wilmington Pump Supply Inc. BOARD OF HEALTH — i �•� Town of North Andover,Mass. Date — ;rmiC hLRM1'1' APPLICATION'FOR WILL & FU Application y ion .is hrmit to drill a well ere � made for pe(•'� PP �plicaC ide to install a pump system. r ..Lot #=_ _ )cation. Address (% AddressJZA D JnC Addresscl '!11 ContractofZ Go5 smp Contractor�� Address/0p ELL CONTRACTOR (To be completed a t i nic of 1)tunp test). •�,�� Well used for YPe of Well ��f9�y Size of Casing iameter of Well .' f Bed Rock;. Depth casing; into L'eci Rock_ epth o �~ a No ( ) Date of Testing i has Seal Tested? Yes ( �5 WeII Ended in Wha.t. Material />�:/;� "I — e p th Gals. )epth to Water? h llelivrr.s I'er titin. for 4 hours hours- at �' GI'M �� .....feet after pumping _ i.. Date of'Completi.on y _ S�t�aLur�?'`�•)eil Contractor ;c :Y : ':'c ..;c ...c Y :• :'- �,%:r ii * :...:r :...., „ .......... ...... ........ is :c ;; ,. ,. ,...., .. ,. ,. ,. ,... ;� :. ,. ,. •� ;, %`• •^ _` in before i nst a�. ation) I ,PUMP INSTALLER (To' -b'6'- f'i.1Tcdf� (7p�rv�t "�. PumpType Used=,n ,. S*i. ze &- Name Pump GPM SiZe of— Water Pump Delivers i1-- Plastic (►�� 'Pipe,,,,;MaCerial Used in Well : Cast Iron (_) Vin) v��ni zed (_) WellPit(_) or Pitless Adapter (Vi" / 1�e11 Scal e? Yes O N O (. }' P c or Name m c l?.it�.Qs=' Was sleeve used to protect Pip _ �� _t_,Il e . Dat �'c9t�t�r�44ttC4�'c�htt4�4�'t�M�4����4�'t�'t�4rrt4Vt�4�4�4�4iM�'c��r�'rtrr'r4Y►'r'rs'r�'rr�rtir,.......,c,c,c Da t e Water analysi's . repor-t 'submitted to Board of Iiealth — Date release given tD owner of record & "14- nSP Ilealt I Tnspector s .' Wilmington Pump Supply 639 Woburn Street Box 517 Wilmington, MA. 01887 Lewis W. Zediana Plant Chemist Tewksbury Water Treatment Plant 71 11nrrimac Drive Tewksbury, MA. 01876 July 3, 1990 .Dear Sirs, The results of the analysis of the water samples submitted on July 2, 1990 from Lot #2 Ingalls Street North Andover, Ma. may be found below.: Test & Result State Limit MCL Type Total Coliform: 0 colonies/ 100 mis. 1 Primary Color: 4.9 Hazen Units 15 Secondary Turbidity: 1.00 NTU 1 - 5 Primary pH: 7.97 6.5 - 8.5 Secondary Alkalinity: 95.0 mg/L as CaCO3 No Limit Hardness: 98.0 mg/L as CaCO3 No Limit Sodium: 19.9 mg/L 250 mg/L Secondary Iron: 0.06 mg/L 0.3 mg/L Secondary Manganese: 0.14 mg/L 0.05 mea/L Secondary Conductivity: 278 umho No Limit i Miss. Guide:line 201.0 ma/ L. LaboratoryMass. Cert ificat ic�r ►?, AtIZ Iii Lewis W. Led 1 .lna 1'l -Int ('{ omi t Tewksbury WTP FORM U +,I TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION, ASSESSORS MAPi(�i� SUBDIVISION LOT (S) '. PERMANENT ADDRESS ASSIGNED BY D.P.W. STREET APPLICANT G ' C%f5S fl{�./�/ PHONE ,309 -53yS DATE OF APPLICATION %/� TOWN USE BELOW THIS LINE PLA NI BOA DATE APPROVED TOWN PLANNER DATE REJECTED VA C0NSE R TION COMMISSION DATE APPROVED CONSERVATION ADMIN. DATE REJECTED !i .BOARD OF HEALT DATE APPROVEDv HEALTH SANITLRIA& DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PER11IT SEWER/WATER CONNECTIONS u or l- c 'FIRE DEPT. 'C2C� t�2eS opt- �c1n.�e2 �Q n,T q- �W t�Jne Sw•e� �. N tt.•.,, t-r Roz-, Kc h t�T o F Fc - �tu-z) 8.3s-100 t---5--r7 *792 RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot This form shall not releive the a licant from the • PP compliance of any applicable Town requirement or Bylaw. Lewis W. Zediana Plant Chemist Tewksbury Water Treatment Plant 71 Merrimac Drive Tewksbury, MA. 01876 July 3, 1990 Wilmington Pump Supply 639 Woburn Street Box 517 Wilmington, MA. 01887 Dear Sirs, The results of the analysis of the water samples submitted on July 2, 1990 from Lot #2 Ingalls Street North Andover, Ma. may be found below: Test & Result State Limit MCL Type Total Coliform: 0 colonies/ 100 mis. 1 Primary Color: 4.9 Hazen Units 15 Secondary Turbidity: 1.00 NTU 1 - 5 Primary pH: 7.97 6.5 - 8.5 Secondary Alkalinity: 95.0 mg/L as CaCO3 No Limit Hardness: 98.0 mg/L as CaCO3 No Limit Sodium: 19.9 mg/L 250 mg/L Secondary Iron: 0.06 mg/L 0.3 mg/L Secondary Manganese: 0.14 mg/L 0.05 mg/L Secondary Conductivity: 278 umho No Limit * Mass. Guideline 20.0 mg/L Laboratory Mass. Certification # MA 126, Analyst: 0 � y - kOL" 67 Lewis W. Zediana Plant Chemist Tewksbury WTP BOARD OF HEALTH 120 MAIN STREET TEL: 682-6483 NORTH ANDOVER, MASS. 01845 Ext. 32 or 33 October 19, 1990 Mr. Walter Casavecchia 32 St. Ann's Ave. Peabody, MA 01960 Dear Walter: I have reviewed the well information submitted by your well driller and the water analysis from the Tewksbury water Treatment Plant. The water analysis is satisfactory as far as this department is concerned, however, I am concerned with the pump test that the well contractor conducted. The contractor indicates in his report that a yield of 10 gal/min. was obtained after a 1 hr. pump test. The Board of Health requires a yield measurement based on a 4 hour pump test. Since this was not done, I will not be able to issue final Board of Health approval until the satisfactory results of a 4 hour pump test is submitted to this office. Also, I still have not received the As -Built Septic System Plan and Construction Certification from your engineer. Until these items are supplied, I will not be able to advise the Building Inspector to issue a Certificate of Compliance. Should you have any questions regarding thistte,/r ease do not hesitate to call. i ' Very/'�4uly y4urs, Mich4dl/.L- Health Agen MJR/rel % k"T; ca CA.) Fn -otY co 90 rLi co "0 mo JU A V < oc :! i % k"T; ca CA.) TEWKSBURY WATER TREATMENT PLANT LABORATORY ANALYSIS SHEET CERTIFICATION # MA 126 `va Iter COLS-To%e-.7, r,�� - G✓ %l Sample From: tiy ; l ty r%-"'nov V @ Address: �S sfi - LAS Phone: City/Town: /V. ,A��oieY State:--L-vi '1 Collected•.�'! n Time:.. ' �fl BY: w'•/'� . PO`^^r . - Received r3 9 By: V Code: c Analyzed 1 D Analyst: �� V, A� Is a-cT BACTERIAL ANALYSIS AT. Coliform: 0100 ml. F. Col iform: __/100 ml. HPC: ------/ml. e„ r k , % L 13 a.c kf roe ✓d INORGANIC ANALYSIS vlf! Tr,sr /`� y , I Color: :�_— color units Turbidity: 1 _• oQ NTU pH: �,% Alkalinity: 5• mg/L Conductivity: _ umho/cm Hardness: � mg/L Chloride: mg/L Fluoride: mg/L Ammonia: mg/L Nitrate: mg/L Nitrite: mg/L Free Chlorine: mg/L Sulfate: mg/L Total Chlorine: mg/L Cyanide: mg/L - Iron:0 (3 6 PPM Calcium: PPM Sodium: l 9� q PPM Zinc: PPM Lead: PPB Mercury: PPB Selenium: PPB Cadmium: PPB Thallium: PPB METALS Manganese: 01PPM Magnesium: PPM Potassium: PPM Other: PPM TRACE METALS Arsenic: PPB Silver: PPB Barium: PPB Chromium: PPB Beryllium: PPB Nickel: PPB Antimony: PPB Copper: PPB June 12, 1990 Merrimack Engineering Services, Inc. 66 Park St. Andover, MA 41814 Re; Lot SA Ingalls St., No. Andover, MA Sentlemene Please be adivsed that the plans dated GIUSO for the septic system design for lot RA Ingalls St. have boon approved for construction subject to natisfactory VW11 installation and testing. Very truly yours, Michael Rosati Health Agent MR/rel l L--f'7-4L, /2e ; Go- 2r/ /.ZS�.1l 15T 1&4�5 4 P;�� /7z- A ; z 77 S�rlc may - / z i CHECKLIST FOR PLAN REQUIREMENTS FOR SUBSURFACE SEWAGE DISPOSAL SYSIENS TOWN OF NO. ANDOVER BOARD OF HEALTH MARCH, 1990 JU (Suggested Scale: 1 = 20007 5. Locus identified. Streets and names within 1/2 mile. C. North arrow and scale S_t_e_.__P1_an (Suggested Scale: 1" = 20' ) _..,____.✓�A. Lot to be served, its dimensions and area. ___._.....,.._... Fronting street. North arrow and scale. D Assessors designation. (Map & Lot Number) _ .. Abutters names and lot numbers. _ Easements. .. _ Property lines. Footprint of proposed IroUse to be. served showing % garage (attached, detached, or garage under house.) �/. Where applicable setbacks to house. Number of proposed bedrooms. Location and elevation of driveway in vicinity of the leaching facility & dwelling. Water service line from main in street or well. __........... _._ Location of existing or proposed well. Location of deep observation ho lr:. s and percolation tests. Existing and proposed contours. Location of bench mark in the vicinity of the leing facility. AD. Location and dimensions of system (septic tank, pipes and leaching facility) including the reserve area. � Profile and section arrows. Location of any streams, water bodies, surface .and subsurface drains, known sources of water supply within 200 -feet, and wetlands within 100 -feet (locate wetlands, specify type of resource and show /100 -foot buffer zone line if applicable). ./r.Erosion control devices as required by Con. Comm. , /Board of Health or Planning Doard with detail and description of device proposed. ,_. Limits of topsoil and subsoil excavations shall be dimensioned clearly on -site plan. CHECKLIST FOR PLAN REQUIREMENTS FOR SUBSURFACE SEWAGE DISPOSAL SYSIENS TOWN OF NO. ANDOVER BOARD OF HEALTH MARCH, 1990 JU (Suggested Scale: 1 = 20007 5. Locus identified. Streets and names within 1/2 mile. C. North arrow and scale S_t_e_.__P1_an (Suggested Scale: 1" = 20' ) _..,____.✓�A. Lot to be served, its dimensions and area. ___._.....,.._... Fronting street. North arrow and scale. D Assessors designation. (Map & Lot Number) _ .. Abutters names and lot numbers. _ Easements. .. _ Property lines. Footprint of proposed IroUse to be. served showing % garage (attached, detached, or garage under house.) �/. Where applicable setbacks to house. Number of proposed bedrooms. Location and elevation of driveway in vicinity of the leaching facility & dwelling. Water service line from main in street or well. __........... _._ Location of existing or proposed well. Location of deep observation ho lr:. s and percolation tests. Existing and proposed contours. Location of bench mark in the vicinity of the leing facility. AD. Location and dimensions of system (septic tank, pipes and leaching facility) including the reserve area. � Profile and section arrows. Location of any streams, water bodies, surface .and subsurface drains, known sources of water supply within 200 -feet, and wetlands within 100 -feet (locate wetlands, specify type of resource and show /100 -foot buffer zone line if applicable). ./r.Erosion control devices as required by Con. Comm. , /Board of Health or Planning Doard with detail and description of device proposed. ,_. Limits of topsoil and subsoil excavations shall be dimensioned clearly on -site plan. � � '../ \ V. Location and elevation of soil tests. ° F�u�d���cm drain outfall shown. ` ' | 3. ^ ` . Percolation rate used for design. Soil log results - designate/ various strata depths and description, depth to ledge and/or groundwater ` if encountered. � � . Date of percolation and deep hole tests. D. Number of bedrooms. Elevation of test pits. 4. (Suggested Scale: 1" = 47> ' A. Finished floor of house. ' =^ . Invert elevations at housev septic tank <inlet & outlet)v and distribution box. If applicable for pump systems; inlet and outlet of pump chamber and pump bloatswitch settings with supporting / calculations.,� Length, type and grade of pipe and length of leaching facility. Elevation of ledge and/or groundwater. Elevation of bottom of leaching facility! Existing and proposed grades. Slope (breakout) requirement and calculations. Scale. . Topsoil & subsoil removal shown. (if applicable) 5. ed Scale: 1" = 41) ~, Elevations of various components. � Existing and proposed grades. Type, dimensions and stone and system components specifications. � Elevation of ledge and/or groundwater. Elevation of bottom leaching facility. Dimensions. Slope (breakout) requirements and calculations. � Scale. I. Too soil and subsoil removal shown. (If applicable) 6. Owner's name, address and phone number. Applicant's name, address and phonenumber. ~� Engineer's namev address and phone number. ____ The designer should indidate any notes or special conditions peculiar to the site of interest to the Boardv Installer or Owner. ^� Plans should be dated. Any revised plans after the ^x initi�n% submission should show a revision date and °~ abbreviated explanation of the revision. _____F. If a pump systemv type, make, model, operation head» performance curve,and pump rates should be provided. All required alarm, power and float switch data should be provided for review and approval. . System components (septic tank, D_box, etc.) details should be provided if other than standard as required from local suppliers. Component spec should be indicated somewhere on the plans for standard items. _____H. Material to replace the topsoiI^ & subsoil shall be specified. (%f applicable.) Reviewed an wmended by: OVi ........ .... . .................. Date Commonwealth of Massachusetts RECEIVED City/Town of NO. ANDOVER System Pumping Record AUG - 6 2007 Form 4 C4,M 'VBy`er TOWN OF NORTH ANDObER I DEP has provided this form for use by local Boards of Health. Oth kWie_he 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. B. Pumping Record 1. Date of Pumping 7/12/07 Date 3. Type of system: H Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ,I No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD /) t5form4.doc• 06/03 — 2. Quantity Pumped: 1500 Gallons Septic Tank ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 7/12/07 Date System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms the computer, use 173 INGALLS RD. only the tab key Address to move your NO. ANDOVER MA 01845 cursor - do not use the return City/Town State Zip Code key. 2. System Owner: MARK GUARINI Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 7/12/07 Date 3. Type of system: H Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ,I No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD /) t5form4.doc• 06/03 — 2. Quantity Pumped: 1500 Gallons Septic Tank ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 7/12/07 Date System Pumping Record • Page 1 of 1