HomeMy WebLinkAboutMiscellaneous - 18 EQUESTRIAN DRIVE 4/30/2018N,
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WATER SUPPLY: OW WELL
WELL PERMIT_ DRILLER
,...... _................. _..... ....... __. _.._..
WELL TESTS: CHEMICAL DATE APPROVED._______._.__.__....
BACTERIA I DATE APPROVED .............._.__.__.._...._......._
BACTERIA II DATE APPROVED.-_____
COMMENTS:
FORM U APPROVALS APPROVAL TO ISSUE YES NO
DATE ISSUED_%-_-._-_-_ BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID NO
+..r+�crorrrnwnnrc](tt�ni YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE �._ Ys_,.._.''I�}
MAP#
LOT #_.____...._._..._......_.__-........__..---._._.._.._
PARCEL #
_ .�....--- ---
STREET._
V.CG._. Y�-n►t..._............. .W
CONSTRUCT.IQN_.APpROVA4
HAS PLAN REVIEW FEE BEEN PAID?
YES
NO
PLAN APPROVAL:
DATE___
Y APP. BY���,
DESIGNER:�✓�
PLAN DATE,______/j�
._
CONDITIONS
WATER SUPPLY: OW WELL
WELL PERMIT_ DRILLER
,...... _................. _..... ....... __. _.._..
WELL TESTS: CHEMICAL DATE APPROVED._______._.__.__....
BACTERIA I DATE APPROVED .............._.__.__.._...._......._
BACTERIA II DATE APPROVED.-_____
COMMENTS:
FORM U APPROVALS APPROVAL TO ISSUE YES NO
DATE ISSUED_%-_-._-_-_ BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID NO
+..r+�crorrrnwnnrc](tt�ni YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE �._ Ys_,.._.''I�}
E.EPT I_G..._SYSTEM_._I NSTALLAT I.ON
IS THE INSTALLER LICENSED? YES NO
TYPE OF CONSTRUCTION: NEW REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO (94V T_
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT CYES NO
� DWC PERMIT N0. _.�(��INSTALLER:._._.....(_.L.!�_.--.��-��1.�...-�...__
............ _.._._.._._._
BEGIN INSPECTION E5 NO:
-...... _.........
_._--.-._-..
EXCAVATION INSPECTION: NEEDED: __----- _
AS BUILT PLAN SATISFACTORY: YES:
APPROVAL TO BACKFILL: DATE:
FINAL GRADING APPROVAL: DATE
FINAL CONSTRUCTION APPROVAL: DATE: ._...,..__........ ........... -...._..BY ............. I .... _......... ............ .........
SUBSURFACE DISPOSAL DESIGN CHECK LIST iLo /A
LOT
APPROVED DATE_ DISAPPROVED DATE_
Provided: Reasons:
&0569 FW-) ZY
Title V
FAIL
Og
Reg 2.5
The submitted plan must show as a minim=:
a) the lot to be served-area,dimensions lot #,abutters
b location and log deep observation holes-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 v&th n 100' of swage disposal
system or disclaimer-Planning -Board iles
(j) known sources of water supply withir. 2001 of sewage disposal d
system or disclaimer
(k) location of any proposed well to ger -e lot-100' from leaching facilit
(1) location of water lines on proper .y-'0' from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
-
Other elevations
(r) maxim= ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authcr:ized by law to prepare such plans
Reg 6
Septic Tanks
(a) capacities-150% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 10, from cellar wall or inground swi mning pool
(d) 25+ from subsurface drains
Reg 10.2
Reg 10.4
Distribution Boxes
(a) slope greater than 0.08
(b) sump '
It
N2 2 0/ 1, 7 Date .......................... �� I..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ............... / ...... / .........................................................................
has permission to perform .......................
........................................................
wiringin the building of .................. 1! ............ I ..................................................
at .f.. .......... . ......... .
- , - -.- -./ North Andover, Mass.
.......................................
...
Fee ... ................. Lic. No .............. .......... --? .......................
ELECTRICAL INSPECTOR
Check # , // / -)
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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4
Commonwealth of Massachusetts
Department of Fire Services
P._. • BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only *907
Permit No.
Occupancy and Fee Checked
(Rev. 11/99] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work- to be performed in accordance with the Massachusetts Electrical Code (NEC), 327 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: in A. &6 VEr To the Inspector of Wires:
By this application the undersigrt d gives notice of his or her intention to pei form the electrical work described below.
Location (Street & Nimber) � q ties -n (, ,n In u
Owner or Tenant PkZ0 �y7�Q Telephone Nol — ..40011
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Semice Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity -,
Location and Nature of Proposed Electrical Work L lacm.�-
No. of Recessed Fixtures
No. of Cei1-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above 11In- ❑
rnd. grnd.
o. o mcrgcncy ighUng
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS INo. of Zones '
No. of Switches
No. of Gas Burners INo.
of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
b
No. of Waste Disposers
(Heat Pump
Totals:Detection/Alerting
I Number I Tons_KW
INo. of Self -Contained
Devices
No. of Dishwashers
Space/Area Heating KW.
Local ❑ Municipal El Other
Connection
No. of Dryers
Heating Appliances KW
SecuritySystems:
No. of Devices or E uivalent I Q
No. o Water KW
Heaters
No. o 0 o
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wirina:
No. of Devices or E uivalent
OTHER:
.,luacn aaaruonar neral y aesurea, or as required by the Inspeclor of 1f'ires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for lite perfonnance of electrical work may issue unless
the licens-- provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
Estimated Value of Electrical Work-. O (When required by municipal policy.) (Expiration Date)
Work to Start: 0 — I _O 1 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I ceriifi, under the pains and penalties of perjury, that the information on thisfapplication is true and complete-
FIR11'I NAME: ADT Security Services 111 Morse Street, Nom4od, MA 02062 LIC. NO.: 1333C
Licensee: John S. Bassett Signatur LIC. NO.: 1333C
(lfapplieabie. cnrcr "exempt"inthc license nunrbcrlinc.) / Bus. Tel. No.: . - — 1
Address: Alt Tel. No.: 603-594-59 resi
OWNER'S INSURANCE WAIVER: I am quare that the Lii`ensee does not have the liability insurance coverage normally ONLY
required by law. By m} signature bclow. I licreby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Oun ' nt r— `. 0O
Signature' Tclpnhnn� No. I PERJIIIT FEE:.� � .l
WILLIAM F. WELD
Govemo:
TOWN OF NORTH ANDOVER/
COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
SUN 2 _ 1999
DEPARTMENT OF ENVIRONMENTAL PROTECTI. N
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
TRUDY CORE
Secretan
ARGEO PAUL CELLUCCI DAVID B. S"IRUHS
Lt. Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
Q PART A
CERTIFICATION
Property Address: / U � � c L / Address of Owner:
Date of Inspection: 10— 57,)�W )qo f,,i (If different)
Name of Inspector: i
I am a DEP approved system inspector rsuantt Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: �� �-
Mailing Address: ett
Telephone Number: s-- 2 V'7/
CERTIFICATION STATEMENT
I certify that l 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewa isposal systems. The system:
_ Passes
_ Conditionally Passes
Needs Further Evaluation By the Local ,Approving Authority
Fails
Inspector's Signature: w Date:
J
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES: v
471 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES: . // 1-4 4
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Paye 1 of 10
DEP on the World Wide Web http:ltwww.magnet. state. ma. ustdep
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued) / /r 4
jam{ ,
Sewage backup or breakout or high static water level observed in the distribution box is due to 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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: or
A,
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
4 WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/A 6A,' CERTIFICATION (continued)lIr
Property Address: /� ��"?v �-/
Owner: ` f
Date of Inspection:
D) SYSTEM FAILS: A
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS: 4 t
You must indicate either "Yes" or No as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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'll of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/15/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
A9 h
Kk-/rf
Property Address: (j'- 4q (1 ell
" e l exp'tl PKI
�/
/
Owner: ! O
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ _ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
r The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub -Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
w h ea /' SYSTEM INFORMATION �J
Property Address:
Owner: �
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:e. /bedroom for S.A.S.
Number of bedrooms: U
Number of current residents:_ `
Garbage gnr.der (yes or no):_X O/
Laundry connected to system (yes or no):�5
Seasonal use (yes or no): /.f
Water meter readings, if available (last two (2) year usage (gpd):A
Sump Pump (yes or no):—N 0
Last date of occupancy: r0cpf P j
COMMERCI.AUI N DUSTRIAL:
Type of establishment:_/
Design flow:_gallons/day
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:
OTHER: (Describe)
Last date of occupancy,:
GENERAL INFORMATION
PUMPING RECORDS and source of information: / te
q
System pumped as part of inspection: (yes or no)- PS
If yes, volume pumped: QU gallons
Reason for pumping t*llt,C'frl i—�//„J
TYPE OF TEM
Septic tank/distribution box/soiI absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:/ /
Sewage odors detected when arriving at the site: (yes or no)'IZ 0
(reviaad 04/]5/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
C,CG1 jSYSTEM INFORMATION (continued) p�
Property Address: %-- L /`''"
Owner:
Date of Inspection: !
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _ cast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction lire•
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: -P
(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 Certificate of Compliance _ (Yes/No)
Dimensions:
Sludge depth:
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 bottom of outlet tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
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:
(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.)
(revised 04/25/91) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �j /t�'f�/ .1 4j L , f` t, /' s Q i, -
Owner: 1.Owner: f Q�
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/dav
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
—/:�
(locate on site plan)
Depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of 1eakage into or out of box, etc.)
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.)
(revised 04/]5/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�i„� �2•-% SYSTEM INFORMATION (continued)
14
Property Address: % /��j�/ tom%~ >l _9
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate.on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: 5- &�xj('-d
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: _
(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 (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
Dimensions:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ` ,r �•y• /V, ' //fj (a
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
(revised 04/25/97) Page 9 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
{ SYSTEM INFORMATION (continued)
Property Address: ..«»
Owner: j"
Date of Inspection:
r
Depth to Groundwaterf! Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
r
(revised 04/25/97) Page 10 of 10
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NORTH ANDOVER BOARD OF HEALTH
SEPTIC SYSTEM
INSTALLATION CHECK LIST
LOT:
PARCEL": t"SIS
MAP
1. DISTANCE TO:
��
a. Wetland �~
b. Drains��
c. Well~oOO'
2. WATER LINE LOCA ION ftO/
�r
3. NO PVC PIPE��
4. SEPTIC TANK
��
a. Tees - Length � To Clean Out Covers
b. Cement Pipe to Tank - On Both Sides of
Tank
5. DISTRIBUTION BOX
a. Covers & Box - No crackso~ �+~
b. All lines Fl g Equal Amounts~�'
c. No Back Flow��
�
6. LEACH FIELD OR T CH
a. Dimensionsw�
b. Stone Depth~
z. Capped Ends��
��
d. Clean Double Washed Stone�
7. LEACH PITS
a. Di ns
Ston 'Depth
c.4, sh Pads
d. TA�~�-
ment P
;p. clean Double WashedvStone
8. NO GARBAGE DISPOSAL
9. FINAL GRADING INSPECTION
10. BARRICADING COVERED SYS7EM
11. AS BUILT SUBMITT
a. Lot Location 07
b. Dimensions of SystemV
z. Location With Regard To Pere Test../
d Elevations