HomeMy WebLinkAboutMiscellaneous - 176 VEST WAY 4/30/2018 (2)t V
Lot & Street
Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit#
Plan Approval:
Designer:
Conditions:
Date:
Approved by:
Plan'Date:
Water Supply: Town Well
Well Permit: Driller:
Well Tests: Chemical Date Approved
Bacteria I Date Approved
Bacteria II Date Approved
Plumbing Sign -Off: Wiring Sign -off:
Comments:
Form °U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid?
Well Construction Approval?
Septic System Construction Approval?
Certification?
Other?
Any Variance Needed?
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES NO
r�
SEPTIC SYSTEM INSTALLATION
CONDITIONS:
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:
YES
NO
DWC Permit Paid?
YES
NO
DWC Permit # Installer:
Begin Inspection: YES NO
Excavation Inspection:
Needed:
Passed: By:
Construction Inspection:
Needed:
As Built Plan Satisfactory:
YES:
Approval of Backfill: Date:_ By:
Final Grading Approval: Date:
M
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
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Applicant
Town of North Andover, Massachusetts
E L H
BOARD %J H A T
DISPOSAL WORKS CONSTRUCTION PERMIT
Site Location A%
)A������
ADDRESS
Form No. 3
Permission is hereby granted to Construct ( ) or Repair (�n Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
0
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CHAIRMAN, BOARD OF HEALTH
Fee / D.W.C. No.
� � — 1114
}
TOWN OF NORTH ANDOVER or
HEALTH DEPARTMENT p
27 CHARLES STREET * "
NORTH ANDOVER, MASSACHUSETTS 01845 CHUS¢S
Sandra Starr, R.S., C.H.O. (978) 688-9540 - Telephone
Public Health Director
(978) 688-9542 -Fax
Ta From:
Fax: Pages:
Phone:
Date:
�11141905�13
�:i7�
❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
Please call 978-688-9540 for assistance with any questions. Thank you.
xc: Address File
Chrono File
HP Fax K 1220xi
Last Transaction
Date Time Type Identification
Log for
NORTH ANDOVER
9786889542
Apr 29 2003 12:30pm
Duration Pages Result
Apr 29 12:29pm Fax Sent 819783736611 1:02 2 OK
R. }
TOWN OF NORTH ANDOVER'
BOARD OF HEALTH
Location
Permit
Food Service
Retail Food
Limited Retail $
Seasonal $
Disposal Works Installers $
Disposal Works Construction
Soil Testing
C
Design Approval Permit $
Dumpster Permit $
Burial Permit $
Swimming Pool Permit $
Animal Permit $
Recreational Camp Permit $
Well Construction Permit $
Funeral Directors Permit $ _
Massage Establishment License $
Massage Practice License $
Suntanning Establishment $
Offal/Trash Hauler $
Other $
6 U S j
Health Agent
White - Applicant Yellow - Dept. Pink - Treasurer
1
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: CURRENT INSTALLER'S LICENSE#
LOCATION: !-
LICENSED INS LLE �NJ
SIGNATURE: ! u_====yXELEPHONE#
CHECK ON
REPAIR: Lll__� NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. e,N al P6 53
M ST / eo/m/\-) /-f/7'y l r Je
Administrative Use Only
$175.00 Fee Attached? Yes t No
Foundation As -built? Yes No
Floor plans on file? Yes No
Approval -2 , Date:
`VI\111 V VV 1 1\V■..i.AVr. ■ V■%■ ■
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION
�aa�:
APPLICANT ��'� , <<� t t� � i �v5 � h t � PHONEl�1
LOCATION: Assessors Map Number < - D PARCEL � L' a
SUBDIVISION ` l , LOT (S)
STREET 1 Z (, ST. NUMBER
i
OFFICIAL USE ONL
V
DATE REJECTED
COMMENTS 11` �/�_i'i_(, �� 1U1 4�i Ut 1 IK -L
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
DATE APPROVED
DATE REJECTED
SEP'TIC INSPECTOR'HEALTHi/ DATE APPROVED , eY '-T, , C) 5
DATE REJECTED
d AMUr-MT4 �( ,CY .1�Li C� 4 -ri 4 Glf- I //fit— 1 -te iYI
PUBLIC WORKS - SEWER/WATER CONNECTIONS
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DRIVEWAY PERMIT
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Town of North Andover
Community Development and Services Division
Office of the Health Department
400 OSGOOD STREET
North Andover, Massachusetts 01845
Susan Y. Sa" er, REHS/RS
Public Health Director
Date:
Address: n(d V �i 1�4
Re: Application for: go r
Dear:
North Andover, MA 01845
nc�-- 0"'" 4, �-n
Your application for at
Department. The application was denied on,
1. V Missing information
2. ❑ Passing Title 5 inspection of septic system required
3. ❑ Location of structure not acceptable
4. ❑ Undersized septic system
To address the problem(s):
(978) 688-9540 - Phone
(978) 688-9542 - Fax
has been reviewed by the Health
2004 for the following reasons:
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition — all rooms
Certified plot plan showing house, septic system and proposed project in scale
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
If #4 is checked:
a. Provide additional information proving that the existing septic system meets current capacity
requirements. Please consult an engineer to determine the flow capacity of the septic system.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
L I
eviewer
Cc: Building Department
File
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TOWN OF NORTH ANDOVER { �8ftT1i
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
27 CHARLES STREET
gtlRRtEo �P¢r�.(wJ
NORTH ANDOVER, MASSACHUSETTS 01.845 "SSACHUSES
978.688.9540 - Phone
Susan Sawyer, REHS/RS 978.688.9542 - FAX
Public Health Director healthdept@townofnorthandover.com
www.townofnorthandover.com
FAX
To: // From:
Fax:
%8 s�/id7
Pages:
Phone: �J �f Date:
U ,
❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
Please contact the Health Department at the above numbers for further assistance.
TOWN OF NORTH ANDOVER NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
o m
HEALTH DEPARTMENT
27 CHARLES STREET 9 -.
°nnreo °*y4y
NORTH ANDOVER, MASSACHUSETTS 01.845 9SSACHU`�ES
Susan Y. Sawyer, REHS/RS
Public Health Director
Date: -Z
TO: Name:
Address:
Attached is the information you requested
978.688.9540 — Phone
978.688.9542 — FAX
healthdept@townofnorthandover.com
www.townofnorthandover.com
Phone:
li
Fax: X,
Please feel free to call the Health Department at the number above if you have any
additional questions. You can also e-mail us at: healthdept@townofnorthandover.com, or
visit us on the web at: www.townofnorthandover.com. Click on "Town Offices" and
choose "Health Department."
The Health Department solicits customer comment, both positive and negative, on the
services that it provides, and continuously seeks to improve service.
If you have any comments on our service, whether a complaint, a compliment or just a
question, please complete the attached form and: mail, fax, or send a general e-mail.
Our goal is to be as helpful as possible, and to provide outstanding service to the residents
of North Andover.
Thank you,
Pamela DefkChiaie
Departmental Assistant
HP Fax K 1220xi
Last Transaction
Date Time Twe
Jul 8 2:47pm Fax Sent
Identification
819785611274
Log for
NORTH ANDOVER
9786889542
Jul 08 2004 2:49pm
Duration Pages Result
1:49 3 OK
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION--
-7/
IDEC MR -
TITLE 5 L._ ,� , � - - -'
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: //l0 !l es- ! a
,-
Owner's Name: a/" fiS
Owner's Address:
Date of Inspection: _ Z --
Name of Inspector: lease print) /'1l� %ix�,
Company Name: / /S G
Mailing Address: CYA D. /
Telephone Number:
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:
Passes
Conditionally Passes
Nee s urther E aluation by the Local Approving Authority
Fai
l
Inspector's Signature: L,- l` ate:
The system inspector shall #bmit a copy of this inspection report to fie Approving Authority (Board of Health or
DEP) within 30 days of cohipleting 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.
Title 5 Inspection Form 6/15/2000
page I
Page 2 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /r�, //V/ ee99 Lam✓
Owner:
Date of In ection:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
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:
_zone 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 or the septic tank (whether im lo not) ot) 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 20yearsold 5 availablei / z- L,4 �i ,, 6 % C m A l�
ND explain:
S 'e P? I C. � c Z,
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: / �� UPST4 Ct i
Owner:
Date of Inspection://
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(i)(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 d
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 analysi' must be attached to this form. r
3. Other:
3
Page 4 of l I
OFFICIAL INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:���
Owner:
Date of Ins ection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes Nq/
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet vert due to an overloaded or clogged SAS or
/'cesspool
V iquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
7ZAny portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for 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.]
(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 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 171p
Owner: ! `
Date of Ins ection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
/Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period ?
_ Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for signs of break out ?
Were all system components, excluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
(oe'o" 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
(/ Existing information. For example, a plan at the Board of Health.
_1,eo" 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: /��o Lf S kl
Owner:
Date of In pection: ZZI
FLOW CONDITIONS
RESIDENTIAL /
Number of bedrooms (design): Number of bedrooms (actual): `7
DESIGN flow based on 310 C 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder (yes or no);N
Is laundry on a separate sewage system (yes or no)j1%[if yes separate inspection required]
Laundry system inspected (y or no): _
Seasonal use: (yes or no/
Water meter readings, if av ilable (last 2 years usage (gpd)):'
Sump pump (yes or no _
I
Last date of occupancy:Q if C, V )91 4
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft,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:
Was system pumped as part of tht inspection (yes or no)• _O
If yes, volume pumped: gallons -- How was uanti pumped determined?
Reason for pumping:
TYP F SYSTEM
Septic tank, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ 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:
Were sewage odors detected when arriving at the site (yes or no):M
6
Page 7of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: I
Owner:
Date of In pection:
BUILDING SEWER (locate on site plan)
c�
Depth below grade:
Materials of construction: ast iron _40 PVC _other (explain):
Distance from private water supply well or suction line:
Continents (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: Z (locate on site plan)
Depth below grade:
Material of construction: 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: (0
Sludge depth: ZZ
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle .,
Distance from bottom of scum to botto utlet tee or baffle:
How were dimensions determined: L)
Comments (on pumping recommendations, let and outlet tee or baffle condition, structural integrity, liquid levels
as outl t invert, eviden e f leaks etc.): '
G.0 � 0 Q � o T f C, xc, N LPA k►
Zei /-IV
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.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: T�tf
Owner
Date of In ection: _ 1.1107
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 r'
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: Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
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.): t
8
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of
SOIL A
If SAS not located explain why:
ate on site plan, excavation not required)
Type leaching pits, number:
leaching chambers, number:
leaching galleries, number:
I hing trenches, number, length:
eaching fields, number, dimensions: 15 o
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,
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): k
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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 'INFORMATION (continued)
Property Address: e2 S ��
Owner: / S
Date of In pection:
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.
10
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: A710
Owner:
Date of Ins ection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells /
Estimated depth to ground watev''o feet
Please indicate (check) all methods Csed to determine the high groundwater elevation:
btained from system design plans on record - If checked, date of design plan reviewed: _
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:
. ' I
Board of Health
a?c..4r .AndovRr,Mass 1
SUBSURFACE DISPOSAL DESIGN CHECK LIST CA
390L
LOT
APPROVED DAT$ DISAPPROVED DATE
Provided: Reasons:
- 'Dt, Vo 6C i��v0 *)0
120E � 69w/ �o� rv'
Title V FAIL
Reg 2.5 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 -distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system -including reserve area
f) existing and proposed contours
g) location any wet areas within 100' of sewage disposal system or
• disclaimer -check wetlands mapping
(h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any drainage easements within 100' of sewage disposal
system or disclaimer -Planning Hoard files
(j) known sources of water supply within 200' of sewage disposal e
system or disclaimer
(k) location of amy 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
Otter elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 I Spic Tanks
(a) capacities -150% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 Brom cellar wall or inground swimming pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope greater than 0.08
Reg 10.4 b) sunp
Subsur'Ace
�.�
Check List
Leaching Pits
2
Leaching pits are preferred Where the installation is possible
Reg 11.2
11.4b)
11.10
?1.11
Reg 15.1
15.4
15.8
3.7
Reg 114.1
14.3
14.1
14.6
14.7
14.10
Reg 9.1
9.6
a) calculations of leaching area-minimam 500 eq ft
spacing
a surface drainage 2%
d) cover material
e) IWIx4" splash pad
f) tee at elbow
g) no bends in pipe from d -box to pipe
Leaching Fields
a no greater 20 minutes/inch
b area -minimum 900 sq ft
c construction of yield
d) surface drainage 2 %
e) 201 from cellar Wall or inground swimming pool
Leaching Wenches
a)caiculauons�Teaching, area -min 500 aq ft
b) spacing -4 ft idn 6 ft -with reserve between
c) dimensions
d) construction
e) stone
f) surface drainage 2%
Downhill Slope
a) slope to be shown)
b) y/x x 150 = (to be shown)
EMS
a) approval
b) stand-by power
Board of Health,
North An¢over3*33.
MAU
�I
10-( (
LOT
F,XgCAVA- CH OK FAIL
1. '.Distance,* To:
RWetlands
b. Drains
c.. well,
2. Water Line tocation"
3. No'M Pipe
4. 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 -wing Equal Amounts
--- c : - - No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Inds
d. Clean Double washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cement Pipe to Pit - .Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. -Final Grading Inspection
10. Barricading Covered system
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location v4th Regard -to Perc Test
d. Elevations
e. Water Table
q
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FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
******************Applicant fills out this section*****************
✓APPLICANT: MWE:2• M P)o I LV)Qy%� IVC Phone Le-.�3_^ 2.0o.
LOCATION:
Subdivision
�tret
Assessor's Map Number
Parcel
Lots) 5
ut--_-�T Q-A-) f 1 St. Number_
************************Official Use Only************************
RECCOOMMENDATIONS OF TOWN AGENTS:
✓ Date Approved i
Conservation Administrator Date Rejected
Comments
Town Planner
Comments
Food Inspector -Health
ep is Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved Vic'/G
Date Rejected
Received by Building Inspector Date
s.. F
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N
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