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Miscellaneous - 18 PENNI LANE 4/30/2018 (2)
ti U 04 n o � 45 mrib 0•8o z �0.9oq.40 � b O V W .� -go d W o d d w b `� f1- d4 w° 'd a y � ; � V C� • ,O a.� 02-21, CHE. O O O O M M M M O M O QtN,ti...N000OwR— N os 00 00 00 00 00 00 r h Z to 9 0 3 00 0 o O � z' M O N O N F A O En O O O En 0 z S S g S Q Q Q " 00 ti ti ti P4 00 Q U °A H m v ..� "C' 0 0 a � � U x � N vii PC z� O O 'w M A z O. 4 U 04 n o � 45 mrib 0•8o z �0.9oq.40 � b O V W .� -go d W o d d w b `� f1- d4 w° 'd a y � ; � V C� • ,O a.� 02-21, CHE. O O O O M M M M O M O QtN,ti...N000OwR— N os 00 00 00 00 00 00 r h Z to 9 0 3 0 0 o � M O N O N F A O O O O 0 z S S g S Q Q Q Q ti ti ti ti 0 0 0 M O N O N cnO N O O O O 0 « 0 N 0 N 0 N N Q Q Q Q P4 00 Q U °A H m Lot & Street Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: Approved by: Designer: Plan Date: Conditions: 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? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION #ONDITIONS: s the installer licensed?. YES NO f ype of Construction: NEW REPAIR Jew Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO ssuance of DWC permit: YES NO )WC Permit Paid? YES NO )WC Permit # Installer: legin Inspection: YES NO _xcavation Inspection: leeded: 'assed: By: :onstruction Inspection: leeded: s Built Plan Satisfactory: ES: pproval of Backfill: Date: By: inal Grading Approval: Date: V\- By: (r nal Construction Approval: Date:_ By: artificate of Compliance: Approval: Date: Commonwealth of Massachusetts _ City/Town of . System Pumping Record Form 4 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. A. Facility Information 1. System Location: Left / Right front of house, Le Ight near of Nous Left/ right side of house, Left/ Right side of building, Left / Right front of building, a Ig rear of building, Under deck Address l ern e City/Town State 2. System Owner. 4 °Z014 APR � Name TOWN O ORT A HEALTH DEPARTMENT Address (d different from location) Citylrown State t-4 r Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes Id No If, yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of System: � j „'� � ✓� � �� 6. System Pumped By.- Nell. y:Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca " ere contents were disposed: a I S. Lowell Waste Water SignAtufe qt Haulej j Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 7 Commonwealth of Massachusetts _ City/Town of System Pumping Record y form 4 DEP has provided this form for us&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. A. Facility Information 1. System Location: Left / Right front of house, Left Right rear of , Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address V lu l Cityrrown 2. System Owner: PD Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State 3 Zip Code Stat _C,,,, iip Code Telephone Number -0"7-1 Q Date 2. Quantity Pumped Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [D' No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: del: k; I V F'=�1' Neil Bateson F5821 9f l It Name Vehicle License Number ULU Bateson Enterprises Inc , Company TOWN Or NOK - H ANDO%ER HEALTH pEPAF�TMENT 7. contents were disposed: i:'d-- 85 --_Cc' Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 �LN Commonwealth of Massachusetts _ _ City/Town of MIC System Pumping Record Form 4 DEC -81011 �M DEP has provided this form for use by local Boards of Health. Other forms aW�H�E�t'Tw " information must be substantially the same as that provided here. Before 01119 L111b WIF11,CI'1M1' our 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. A. Facility Information 1. System Location: Left / Right front of house, LeffiQE rear of hou , Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Cityrrown 2. System Owner: Name Address (if different from location) Cityfrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) State Zip Code State Zip Code s© C4-1?C)6 r Telephone Number — 2. Quantity Pumped Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ®–N_o_� If yes, was it cleaned? ❑ Yes ❑ No 5. Condi on System - 10,07 \ �- � 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loca ' here contents were disposed: G.L,S. Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms`on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of RECEIVED System Pumping. Record MAR 2 7 2009 Form 4 AKirtr DEP has provided this form for use by local Boards of Health. Other fo ms- i fhe 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. A. Facility Information 1. System Location: Left front, left rear, left side of house. Right front, �ih right sid of house. Address City/Town 2. System Owner: Name Address (if different from location) City/Town State Zip Code Stat' �^� � Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Cesspool(s) Septic Tank 0 Tight Tank Q Other (describe): 4. Effluent Tee Filter present? C] Yes, No If yes, was it cleaned? p Yes No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio contents were disposed: /6L -S -6' --/Lowell Waste Water 73 igna ure of H u r Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RE LVED City/Town of System Pumping Record APR 0 3 200 Forrn 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information .Important: When filling out 1. Sys em Location: foims computeto r,.use.use only the tab key Address , to move your cursor - do not Peon �f C '�f�-'✓ use thereturn Cih'rrown State Zip Code key. 2. System Owne Name Address (if different from location) City/Town State Zip Code 96� Telephone Number B. Pumping Record Q C 1. Date. of Pumping tl 2. Quantity J Date ty Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5: Condition of System: 6. Syste�p�y' Name Vehicle License Number Company .7. Location where contents we isposed: Si at of uler Date http://www.mass.goqv/dep at /approvals/t5forms:fitnn#inspect t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1 Town of North Andover tkORTJ Office of the Health Department a 00, Community Development and Services Division * - _y 27 Charles Street �A4TED P� North Andover, Massachusetts 01845 9"S USEs Susan Y. Sawyer, RENS/ RS 978.688.9540 - Phone Public Health Director 978.688.9542 - Fax TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE April 5, 2004 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by Todd Bateson at 18 Penni Lane North Andover, MA 01845 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Susain Y. Sawyer, REH Public Health Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 'A"N OF NORTH ANDIU'W ER/ BOAPD OF HEALTH AIR 5 200 TOWN OF NORTH ANDOVER INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (./l repaired: by T017D LD located at j Qj �F jr M was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # , dated with an approved design flow ofd gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bed inspection date: -1 1eq- Engineer Representative Final inspection date: 10 - Engineer Repre ntative Installer: �`` ' :#: Dater Design Engineer:eptcLlADate: x 1A .✓ i 0 O L^0�- AS -BUILT CHECKLIST LOT NUMBER, STREET NAME v} MAR ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS \.-� LOCATIONS & DIMENSIONS OF SYSTEM, TIES TOS & DWELLING, OA. a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN ISO' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC, NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED tiA rwpL L^o�- AS-BUILT CHECKLIST LOT' NUMBER, STREET NAME 10AFto ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS X94 LOCATIONS & DIMENSIONS OF SYSTEM, . TIES TO t0443RES & DWELLING, OA_ a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX = ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED Page 1 of 1 Pamela DelleChiaie From: "Dan Ottenheimer" <info@millriverconsulting.com> To: "'Pamela DelleChiaie"' <pdellechiaie@townofnorthandover.com> Cc: "'Heidi Griffin"' <hgdffin@townofnorthandover.com> Sent: Tuesday, September 30, 2003 11:22 AM Subject: RE: 18 Penni Lane - Bottom of Bed Inspection Request All set for today at 3:30. Dan Mill River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 info@millriverconsulting.com -----Original Message ----- From: Pamela DelleChiaie [mailto:pdellechiaie@townofnorthandover.com] Sent: Tuesday, September 30, 2003 9:50 AM To: Dan Ottenheimer Cc: Heidi Griffin Subject: 18 Penni Lane - Bottom of Bed Inspection Request Importance: High Hi Dan, Can you arrange a time to do a Bottom of Bed Inspection for 18 Penni Lane? Please call Todd Bateston at: 978.815.2703. Thanks, Pam 9/30/2003 r Page 1 of 1 Pamela DelleChiaie From: "Dan Ottenheimer" <info@millriverconsulting.com> To: "Heidi Griffin"<hgriffin@townofnorthandover.com>;<blagrasse@townofnorthandover.com>; <pdel lechiaie@townofnorthandover.com> Sent: Wednesday, October 01, 2003 12:53 PM Attach: Construction Inspection Form Penni Lane #18.doc Subject: 18 Penni Lane Heidi, Brian and Pam, Attached ,please find the inspection report for the bottom of bed inspection at 18 Penni Lane. No problems encountered. Dan , Mill River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 info@millriverconsulting.com 10/1/2003 TOWN OF NORTH ANDOVER SEPTIC SYSTEM CONSTRUCTION NOTES GRAVITY DISTRIBUTION ADDRESS: 18 Penni Lane MAP: 107D LOT: 58 INSTALLER: Todd Bateson DESIGNER: Merrimack Engineering PLAN DATE: 8/6/03 SEPTIC TANK Date & Initials INSPECTIONS ❑ Bottom of tank hole has 6" stone base 9/30/03. Mill River 0 1500 gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) 9/30/03. Mill River x❑ Water tightness of tank has been achieved x Visual Vacuum Test Water held for 24 hrs 9/30/03. Mill River Inlet tee installed 9/30/03. Mill River ❑O Outlet tee with gas baffle/effluent filter installed 9/30/03. Mill River 0 20 inch cover to grade installed over outlet of tank if effluent filter ❑ Hydraulic cement around inlet & outlet Comments: Outlet cemented, not inlet yet. 9/3/0/03 Page 1 of 2 D -BOX Date & Initials INSPECTIONS ❑ Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution Speed levelers (not required) Comments: SOIL ABSORPTION SYSTEM Date & Initials INSPECTIONS 9/30/03. Mill River 0 Bottom of SAS excavated down to C soil layer ❑ Title 5 sand installed ❑ 3/4-11/2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ laterals installed and ends sapped of connected to header (and vented if impervious material above) size: ❑ orifices @ 5 & 7 o'clock positions ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: Page 2 of 2 i M Lo ON M z ' 0 N �:. a. m �� 00: : as /1 M� U � o ; V1► z vCUi M 4 > Cl) o 0 Q O o V CU ` o cn o ° m Z 0 as E b� � 0 o U cu a O A c A Cl) '"�' a ti � � •a a M i 0 � co �- G z O i k;wl APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: l ' CURRENT INSTALLER'S LICENSE# LOCATION:—J,3- 7�Al / LICENSED INSTAL 11:7�_4`z3' eA--, SIGNATURE: TELEPHONE# �� �V-3 CHECK ON : REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION; PLEASE ATTACH FOUNDATION AS -BUILT. Admin' trative Use Only >$._00_Fee Attached? Yes No Foundation As -built? Yes No Floor plans o it Yes No_ Approval Date: `Z 1 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North. Andover licensed installer for the construction of the septic system for the property at N ` relative to the application of214J2. /V dated / l01 for plans by I lhk: Wool 4Ny and dated with revisions dated . I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contracto project manger, or any other person not associated with my company schedules an inspectio and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicabl inspections as indicated below. I understand that requesting an inspection,. withou completion of the items in accordance with Tile 5 and the Board of Health Regulations ma, result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally.first inspection unless there is a retaining wall which should be don, first. Installce st request the inspection but does not have to be present. b) Final inspection —.Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK from engineer must be submitted to Board of Health, after which installer calls fo, inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready .and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the, system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank; D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Septic Installer Date: C - `� Disposal Works Construction Permit # GDS F&-Zw1r / e 7Z�Y-N / OK It �5�s in, re'�5erv8 CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS Job The following is a checklist that incorporates all Title 5 and local regulations for septic pians. Name of Applicant: ye �(5 () /;e—' SS Name of Designer:0, zJ �✓e S Ol Plan Date: Revision Date: Date of Review: Property Address: Map: 16 7P Lot:8 / �J BOH Reviewer: �� Type of Plan (new or upgrade): V q cO 1 Number of Bedrooms: gpd) - SsJb Garbage Disposal Allowed:11ln— General Information: N.A. = North Andover Septic Regulations Other numbers refer to Title 5 OK/ Problem N/A Street number and map/lot - 220(4)(u) —�- Maximum scale of 1 "=40' for plot plan - 220(4) "=20' Maximum scale of 1 for profile and component details - 220(4) Legal boundaries of the facility being served - 220(4)(a) Names of abutters from recent tax map - NA 8.02j Number of bedrooms, design calcs., - NA 8.02i Name & address of record owner & applicant - NA 8.02k Name & address of designer - NA 8.021 Holder and location of all easements - 220(4)(b) Date plan drawn & any revision date - NA 8.02m —� All dwellings and buildings, existing and proposed - 220(4)(c) e/r Location of all existing or proposed impervious areas - 220(4)(d) All distances on site plan — NA 8.03a -c , Elevation of proposed driveway - NA 8.02t Location and elevation of foundation drain - NA 8.02y 4z Location and dimensions of the system incl. reserve (new const.) - 220(4)(e) -f Limits of excavation of leach area on site plan - NA 8.02z Locus plan - 220(4)(t) (Not to scale) North arrow - 220(4)(g) Existing and proposed contours - 220(4)(g) Locations and logs of deep holes - 220(4)(h) Locations and logs of percolation tests - 220(4)(i) Date(s) of soil testing - 220(4)(h) & (i) Existing grade elevation of each deep hole - 220(4)(h) Elevation of percolation tests — N.A. 8.02n Name of approving authority representative - 220(4)(h) & (i) Name of soil evaluator - 220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines, drains, and subsurface utilities - 220(4)(m) Observed and adjusted g.w. elevation in the vicinity of the system - 220(4)(n) Complete profile of the system to scale - 220(4)(o), NA 8.02c Cross section of leaching facility - NA 8.02w (Not to scale) Location of benchmark(s) within 50-75 feet of facility - 220(4)(q) 41� Note listing all variance requests with proper citations - 220(4)(p) El—�� Local upgrade approval request form submitted - 403(1) 2` Original R.S./P.E. stamp, signature & date - 220(1) & (2) P.E., discipline specified within stamp. MGL C. 112 s. 81M sfc. supplies (w/in 400'), pub. wells (w/in 250'), pvt. wells (w/in 150') - 220(4)( Location of watercourses, wetlands, wells, etc. w/in 150' of system — NA 8.02r Wetland disclaimer — NA 8.02s RLS plan reference & certification required (prop line setbacks) - 220(3) Plan contains designer's certification statement Use approvals / standards checked for I/A system - DEP docs., tPerc rate >30 MPI - not allowed for new, LUA for upgrade - 245(1)&('3) Perc rate > 60 MPI - must use modified tight tank or UA technology - 245(4) Proposed system qualifies as "shared" system - 002 (definitions) Flow is over 2,000 gpd - No R.S. allowed - 220(1) Design flow was set in accordance with code - 203 _ Existing system location and note on proper abandonment - 354 Leaching facility at least I' above Base Flood elevation — NA 9.05 All piping Sch 40 minimum — NA 10.01 / Basement floor minimum i' above groundwater elevation — NA 5.04 Foundation drain present with elevation — NA 8.02y On-site Soil and Groundwater Review OK /Problem N/A �/ Proper deep observation hole logs on plan - 220(4)(h) All deep holes and peres .shown, including aborted tests — NA 8.02n Soil evaluation forms submitted within 60 days of field work - 018(2) Proper percolation test log - 220(4)(i) Ample deep observation holes in primary disposal area (minimum 2) - 102(2) t/ Ample deep observation holes in secondary disposal area (minimum 2) - 102(2) Ample perc testing (one in each disposal area, 3 in prim. > 2,000 gpd) - 104(4) Deep hole testing conducted within two years — NA 7.05 Hole Identification Numbers: ground elevation el. �I acceptable soil el. Leach facilitv invert el. ?RIO I'$3 ground water el. c%J�, g S3, refusal el. 77, F7 bottom of leach facility el. 27, v 9T. thickness of acceptable soil 76 before & after soil R&R separation to groundwater ! �� separation to refusal soil class 0 ir 3 perc rate loading rate septic tank below g.w. table pump tank below g.w. table l.f in fill /l ,"l;p �-- (yes or no) (yes or no) -255(l) Setback Distances (Given in feet)15.21 1 YES ,NO Is the lot in the Lake Cochiewick Watershed? NA 6.00 & 5.02 OK Problem N/A Septic Tank Leach Facility Property line 10 10 Cellar wall 10 20 Inground pool 10 20 Slab foundation 10 10 Deck, on footings, etc. 5 10 V Waterline 10 10 ,Private drinking well 75 100 ✓ Irrigation well 75 100 / Wetlands 75 100 Public well 400 400 v Wetlands bordering surface 150 150 water Supply or trib. (in Watershed) z/ Trib. To Surface Water supply 325 325 Reservoirs 400 400 Tributaries to reservoirs 200 200 Drains (wat. supply/trib.) 50 100 Drains (intercept g.w.) 25 50 Foundation drains to 20 Drains (Other) 5 10 Drywells 20 25 v Downhill slope 15' to 3:1 slope 3 w/o barrier Building Sewer OK Problem N/�. Grease trap required for certain uses (check 230 for details) Pipe diameter listed (4" minimum) - 222(1) Pipe schedule listed - 222(3) _�✓ Pipe cast iron or Sch 40 -PVC — NA 11.02 Watertight joints specified - 222(3) & (4) Pipe laid on compact, fin base - 222(5) Pipe laid on continuous grade in straight line - 222(7)@ Cleanouts precede all changes in alignment and grade - 222(8) ✓ Cleanout provided every 100 feet - 222(8) Manhole at any 90 degree alight change - 222(8) Invert `/ L7 elevation at building: �✓ -� Invert elevation at septiink: Length �pZZ of run: Slope: `b (minimum of 0.01 - 0.02 desired) - 222(6) 10' offset to private well or suction line - 222(2) Septic Tank 4 4 OK Problem N/A Tank is accessible - 228(3) No structures above tank — (228(3) Tank can accommodate both primary & reserve — NA 9.04 200% of flow (required & provided given. 1500 min.) - 220(4)(f) & 223)(1)(a) 2-3" drop from inlet to outlet - 227(5) Minimum of 4' liquid depth - 223(2) 3" air space above tees/baffles (minimum) - 227(4) ✓ 9"air space above flow line (minimum) - 227(4) Tees are not to be replaced by baffles - 227(1) L7 Tees extend 6" above flow line - 227(1) - Inlet tee extends 10" below flow line (minimum) - 227(6) Outlet tee extends 14" below flow line (more for deeper tanks) - 227(6) Gas baffle installed on outlet - 227(4) Access manhole cover above center of tank & each tee (except 2 compart) / 228(2) 3-20" manholes - 228(2) 1 childproof; 24" riser/manhole w/in 6" of final grade if <1000gpd- 228(2) Inlet and outlet tees on center line - 227(1) Soil compaction below tank specified (if soil is non-native) - 221(2) 6" <=3/4"stone beneath of tank specified - 221(2) & 22 8(1) z✓ If> 1,000 gpd AND not a single fam. dwell. must be 2 tks or 2 comp. - 223(1)(b) If plan specifies disposal must be 2 tanks in series or 2 compart. tank - 223(1)(c) Buoyancy calcs. required if tank at or below water table - 221(8) Tank is watertight - 221 (1) 9" of cover over tank (minimum) - 228(1) H- 10 loading (min.) - H-20 if traffic - 226(3) Top of tank <=36" below grade - 221(7) All pumping to tank (if applies) in accordance with - 229 -�- Tank is set to keep old system in service during install if possible 4 A �V Tight Tank (Check here if not present: ) OK Problem N/A 500% of design flow or 2000 gallons provided — 260(2)(a) 3- 20" manholes — 228(2) Soil compaction below tank specified (if soil non-native) —221(2) 6" of <=3/4" stone beneath tank specified — 221(2) & 228(1) Buoyancy calcs. Required if tank at or below water table — 221(8) Tank is watertight — 221(1) 9" of cover over tank specified (minimum) — 228(1) H-10 loading (min.) — H-20 if traffic — 226(3) Top of tank <= 36" below grade — 221(7) All pumping to tank (if applies) in accordance with — 229 A/V alarm set at 3/5 tank capacity — 260(2)(c) Min. 1-24" frame w/cover at finished grade — 228(2)(f) Year round access for pumping — 228(2)(g) Distribution Box (Check here if not present: ) OK Problem N/A Pump Chamber (Check here if not present: ) OK Problem N/A Volume specified: AN,) 9 220(4)(r) / Pump on elevation- 7o . 9 % 220(4)(r) Pump off elevation: YO -220(4)(r) L Alarm on elevation: 3 . AZ 7 220(4)(r) Number of cycles per day - 220(4)(r) (also 254(1)(d) if gravity from d -box) — 'y Minimum 2" delivery line to d -box if gravity - 254(1)( c) Pressure dosed l.f if flow >= 2,000 gpd - 254(1)(a) & 254(2)(a) _ Cycles per day is consistent with chamber volume - 23 1 -� Volume calculations include flowback volume - 2') 1(2) Inlet elevation: Outlet elevation: , �J 0.17' drop from inlet to outlet (minimum) - 232(3)(b) 6" sump (minimum) - 232(3)(e) All outlets at same elevation - 232(3)(b) i/ Outlet pipes laid level for first 2 ft. - 232(3)(c) IZ Pipe Sch 40 - NA 10.01 r Number of outlets: Number of laterals: lg Size of outlets: Y Inlet bale/tee min. 1" over outlet invert for all d -boxes - 232(3)(a), Soil compaction below distribution box specified (if soil is non-native) - 221(2) s� 6" of stone beneath distribution box specified - 221(2) Box is watertight - 221 (1) Top of box <=36" below grade - 221(7) Buoyancy calculations required if box is at or below water table - 221(8) Pump Chamber (Check here if not present: ) OK Problem N/A Volume specified: AN,) 9 220(4)(r) / Pump on elevation- 7o . 9 % 220(4)(r) Pump off elevation: YO -220(4)(r) L Alarm on elevation: 3 . AZ 7 220(4)(r) Number of cycles per day - 220(4)(r) (also 254(1)(d) if gravity from d -box) — 'y Minimum 2" delivery line to d -box if gravity - 254(1)( c) Pressure dosed l.f if flow >= 2,000 gpd - 254(1)(a) & 254(2)(a) _ Cycles per day is consistent with chamber volume - 23 1 -� Volume calculations include flowback volume - 2') 1(2) M Leaching Facility (general - complete for all designs) OK Problem N/A 24 hour storage capacity above pump on elevation - 231(2) Number of pumps: 2 if system serves >2 dwelling units - 231(6) Capacity of pump(s)— gpm @ �;!, 7 ' TDH - 220(4)(r) Trenches to be used whenever possible - 240(6) Pump'can pass 1 1/4 "solids (minimum) - 231(7) _ Pump controls specified - 220(4)(r) Alarm equipment specified - 231(2) Vented if under impervious cover - 241 (1) Alarm is in building and powered on separate circuit from pump - 2') 1(9) Pump sequence correct (off -lead on -lag on-alan-n on) - 231(8) s� Pump performance curves included - 220(4)(r) Vent protected from precipitation/animal entry - 241 (1)(b) Manual operating switch - NA 12.01 _1 Check valve, bleeder hole - NA 12.01 y/ 1 childproof; 24" riser/manhole to final grade - 2'31(5), All lines connected to vent if bed or trenches - 241(1)(d) Soil compaction beneath pump chamber specified (if soil is non-native) - 221(2) 6"of <=3/4"stone beneath chmbr. specified - 221(2) & 228(1), r—ice Buoyancy calculations if chamber is at or below water table - 221(8)@ Reserve area provided (new construction) - 248(1) 9" of cover over chamber (minimum) - 228(1) H 10 loading (min.) - H-20 if traffic - 226(')), ✓ Chamber is watertight - 221 (1) a! Top of chamber <=36" below grade - 221(7) Leaching Facility (general - complete for all designs) OK Problem N/A 50% larger if garbage disposal - 240(4) Trenches to be used whenever possible - 240(6) No vehicle or imperv. area above l.f. unless unavoidable - 240(7); NA 13.02 Vented if under impervious cover - 241 (1) Vented through same pipes as distribution system - 241 (1)(a) s� Vent protected from precipitation/animal entry - 241 (1)(b) Vent is placed beyond traffic or impervious area - 24 1 (1)(c) All lines connected to vent if bed or trenches - 241(1)(d) 9" cover over peastone - 240(9) r—ice Reserve area provided (new construction) - 248(1) ✓ r Reserve 4' from primary leach area – NA 9.04 4' (5' if perc rate <=2 MPI) separation to g.w. - 212(a) & (b) 4' (down to 2' with variance or I/A - upgrades only) of natural soil under Lf. GW separation is adjusted to highest existing grade if facility cuts into a hillside Pipe slope minimum of 0.005 - 251(9) ✓ Require 5' removal and replacement if in fill - 255(5) Top of leach facility <= 36" below grade - 221(7) ✓ Final grade over 11 minimum 0.02 ft/ft -240(10) Surface & subsurface drainage away from l.f. - 240(1 1) & 245(5) Minimum design flow 440 gpd without deed restriction – NA 13.01 �j 3:1 slope where grading required - 255(2) Toe of fill slope stops 5' from property line or swale installed - 255(2) Impermeable barrier if < 3:1 slope or < 15 feet to –3:1 slope - 255(2) Impermeable barrier/retaining wall poured concrete – NA 9.02 Retaining wall stamped by P.E. - 255(2)(b) C� Top of retaining wall >= top of peastone elevation - 255(2)(f) 10' offset from edge of leach facility to edge of ret. wall - 255(2)(g) C-- Perc test(s) done in most restrictive layer - 104(2) Perc test 4' below leaching elevation – NA 7.06 Design flow listed and required/provided leach area given - 220(4)(f) —� Leach pipes SC1140 PVC – NA 10.01 Leach pipes minimum 4" diameter except for dosed system – NA 14.04 .Iq% M'✓ Leach lines capped, vented, or connected together - 251(9) _ t/ Pressure dosing guidance followed if pressure distribution - 254(2)(c ), Pressure dosing required over 2,000 gpd or with UA remedial use - 231(1) Leaching Trenches (Check here if not present: ) OK Problem N/A Number of trenches: Minimum of 2 trenches - NA 9.01(2) Depth of trenches (max eff. 2'): -247(1) Width of trenches (2' min., 4' max.): - 251 (1)(b) Length of trenches (100' max.): - 25 1 (1)(a) Trenches are vented (when > 50') - 251 (11) Trenches follow contour lines - 251(2) Trench spacing 3 times effective width or depth minimum- 251 (1)(d) In fill or reserve between trenches, 10' min. - NA 14.01& 14.03 Available leach area given (Min. 500 s.f.) - NA 9.01(2) Bottom = L x W x # = s.f. Sidewall=L x x# x2= s. f. Effective leach area given Loading factor: Effective area = total area s.f. x LTAR = g/day Effective area is >= design flow of facility being served 2"of 1/8"- 1/2" 2x washed peastone.- 247(2) Trench depth of 3/4" to 1 1/2" double washed stone - 247(1) Leaching. Pits (Check here if not present: OK Problem N/A # of pits/pit systems: (dosing chamber if>1, 231 (1)) Dimensions of each pit or system: L W D Depth of pits (max eff. 2'): - 253(1)(a) Available leach area given Bottom = L x W x # of systems = s.f. Sidewall = L+ W x D x 2 x# of systems = s. f. Total area = bottom + sidewall = s.f. Effective leach area given Loading factor: Effective area = total area s.f. x LTAR = —g/day Effective area is >= design flow of facility being served Minimum of 2 pits at least 13'X16' — NA 9.01(3) Distribution for galleries/chmbrs. in trench config. - pipe every 20' - 253(6) Distribution for galleries/chmbrs. in bed config.-ea.pipe serves <= 40 s.f.-253(6) Spacing - 2 times the effective width or depth (the greater) - 253(1)(c) 2"of 1/8"- 1 /2" 2x washed peastone.- 247(2) 3/4" to 1 1/2" double washed stone - 247(1) Each pit has at least one 20" access cover. 24" CI to grade over 2,000 gpd -253(3) Surrounding aggregate thickness between 1' (min.) and 4' (max.) - 253(1)(b) Vents, if necessary, extend under covers of pit(s) - 241 (e) Leach Fields (Check here if not present: ) OProblem N/A V Number of fields: (need dosing chamber if> 1, 231 (1)) 7 Final Grading OK /Problem N/A V 5/24/01 Length (100' max.): --,/C/i - 252 (2)(b) Width: Total area: L x W Minimum 900 square feet - NA 9.01(1) Distribution lines connected with solid pipe — NA 15.01 Effective leach area given Loading factor: ' 6�6 Effective area = total area 146Z,) s.f x LTAR °c3� _� g/dav Effective area is >= design flow of facility being served Minimum of two distribution lines - 252(2)(a) 6' line separation (max.) - 252(2)(d) -4' maximum separation from edge of field to line - 252(2)(e) 10' minimum separation between adjacent leach fields - 252(2)(f) Between 6" and 12" of 3/4 - 1 1/2" stone beneath field - 252(2)(g) & 247(2) 2"of 1/8"-1/2" 2x washed peastone.- 247(2) Slope over leach area minimum of 0.02 feet/foot — 240(10) Grading shall divert drainage away from leach area — 240(l 1) Grading slopes away from dwelling J 8 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permitsS Boards and Departments having jurisdiction have been obtained. This.doeno relieo s ve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT 7., PHONE .1t 0i1°'3'3 LOCATION: Assessor's Map Number �1 PARCEL SUBDIVISION LOT (S) STREET_ ,✓ e r•�� ST. NUMBER USE ONLY *********** ATION AGENTS: DATE APPROVED DATE REJECTED COMMENTS s TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC TH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR -DATE--. Revised 9197 jm TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr, R.S., C.H.O. Public Health Director FAX f t10RTH � ,�S,,BG 8 tiO 0 � 9SSACHUSEt Telephone (978) 688-9540 FAX (978) 688-9542 Bill Dufresne From: Pamela for Sandra Starr To: MERRIMACK ENGINEERING 66 PARK STREET Andover, MA 01810 Fax: 978-475-1448 Pages: 97.8-475-3555 Phone: Date: Septic Plan Response CC: Sandra Starr, R.S., C.H.O. Re: Health Director ❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: Attached is the response from Sandra Starr regarding Septic Plans for the following property: . A copy has also been mailed to the homeowner. Please call 978-688-9540 for assistance with any questions. Thank you. Cc: File Homeowner Building Dept. HP Fax K 1220xi Last Transaction Date Time Aug 12 1:56pm Tyke Identification Fax Sent 89784751448 Log for NORTH ANDOVER 9786889542 Aug 12 2003 1:58pm Duration Pages Result 1:40 3 OK G .y.• < Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Public Health Director Telephone (978) 688-9540 Fax(978)688-9542 Bill Dufresne August 12, 2003 Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 18 Perini Lane, North Andover Dear Mr. Dufresne: Please be advised that the proposed plan dated 6/30/2003 and revised 8/11/2003 for the upgrade of the septic system at 18 Penni Lane has been approved. Should you have any questions, please do not hesitate to call the Health office. Sincerely, Sandra Starr, Health Director Cc: tllf4le Homeowner Building Dept. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALT11688-9540 PLANN NIG 688-9535 SEPTIC PLAN SUBMITTAL FORM LOCATION: V NEW PLANS: 6�s $ � PIan ✓� 5�`� REVISED PLANS: YES $ 60.00/Plan SITE EVALUA'T'ION FORMS INCLUDED: NO TOS VARr� HEAD DATE: DESIGN ENGINEER: DATE TO CONSULTANT: When the submission is all in glace, route to the Health Secretary. Location: [V--- Vokili 1, L A )K 1 owner's Name: Installer: Address: .182 Veu -)L, I 4 -,Oe Tel g: (663-9600 New tsisol Repair ✓ Date: % - L L -op— Wetlands2Lw--one II —~ Soil Symbol G� Soil lQame jj_Son Class_3 Deep Observation Hole Logs Elevation Depth Soil Horizon Soil Texture Soil Color Soil Mottling % Gravel, Stones, etc: ,• Id d FSG ? LU M Parent Material 41 L, -L, - Depth to Bedr*&':: Standia= Yater is the Hol- O Z L q;eepfn= from Pit Faee -7G • • �HG%Y; �te ,Z te4NU ,R'- 10 4k Gt 3r} ('oi 4 ►2� I1ty �}TZ s Z, y ► �� y/� VIA" IV gr Parent Material Depth to Bedrock:'—"� Sbnft= Nater in the Hole:q!9;—Weepin; from Ph Faee-9V ESHG%Y: Date Tests Obsei Deptl Start Time Time Time Time Rate Performed B ; aK Witnessed Br-�'jle MERRIMACK ENGINEERING SERVICES INC. Engineers • Surveyors * Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 (978) 475-3555 Fax (978) 475-1448 TO WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via ❑ Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ ��� u �� OLI lJ D � LJV�JLJVLJ� LJ LI�� DAT � JOB NO. ATTENTION RE: U Al r% n the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION THESE ARE =S_rarp)orc MITSED as checked below: val ❑ For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE REMARKS COPY TO ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US SIGNED: n� �z if enclosures are not as noted, kindly notify us at once. h o 0 O i - 0 40. A 0 O U w z z O N 0 •'O.+ w N bD C N W c o 3 CZ M c UU � �03� �on�0 ca E st p 42 > 3 ani o .L, a "> y . 00 d q u, T � j wY°, N 00 •d v o O C o a L- o � � U c0 ,a 'O b viO O a > a3i y�xy��^'@oo--s ¢¢�Aa�w°uo�U�a`i' O � ) 7 7 M O O v O O M M M M O O M M M M O M O o 7 O M d� M N ON •..� N 00 •-� •--� � h � 00 00 00 00 00 00 t- i-- N CIO In �n 1 In R \o �o �o 10 � o 0 0 z 0 d o W o 0 0 0 � N W N � a � � ti ti ti ti G N m � O � N 0 Q O . U c a y � H a � a o0,z„ O c ai w Com., rZ O 00.00 ti C, O 0 O i - 0 40. 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Page 1 of 1 DelleChiaie, Pamela From: Dan Ottenheimer [info@ millriverconsulting.com] Sent: Thursday, October 16, 2003 1:23 PM To: Heidi Griffin; blagrasse@townofnorthandover.com; pdellechiaie@townofnorthandover.com Subject: 18 Penni Lane Heidi, Brian and Pam, Attached please find the construction inspection report for 18 Penni Lane. Everything proceeded smoothly with this job. The contractor and designer did decide to change the pump from the one specified on the approved plan. I requested that a new pump curve and calculation be submitted to your office by the designer prior to issuance of the Certificate of Compliance. If you think of it and wish us to review the new information feel free to forward it along. Dan Mill River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 info@miliriverconsulting.com 10/16/2003 (w C5 r Page 1 of 1 DelleChiaie, Pamela From: Dan Ottenheimer [info@milldverconsultng.com] Sent: Thursday, October 16, 2003 1:23 PM To: 'Pamela DelleChiaie' Cc: blagrasse@townofnorthandover.com Subject: RE: 18 Penni Lane - Final Inspection All set for 3:30 this afternoon (10/7). Mill River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 info@millriverconsulting.com -----Original Message ----- From: Pamela DelleChiaie[mailto:pdellechiaie@townofnorthandover.com] Sent: Monday, October 06, 2003 8:53 AM To: Daniel Ottenheimer (E-mail) Cc: Lagrasse, Brian Subject: 18 Penni Lane - Final Inspection Hi Dan, Bill Dufresne left a message on the machine this a.m. — He said that 18 Penni Lane is ready for a final inspection. Todd Bateson is doing the work. Todd's number is: 978.815.2703. Please call to schedule. Thank you. Pamela DelleChiaie, Health Dept. Assistant Town of North Andover Community Development & Services 27 Charles Street North Andover, MA 01845 pdellechiaie@townofnorthandover.com Tel. 978-688-9540 Fax 978-688-9542 10/16/2003 TOWN OF NORTH ANDOVER SEPTIC SYSTEM CONSTRUCTION NOTES GRAVITY DISTRIBUTION ADDRESS: 18 Penni Lane MAP: 107D LOT: 58 INSTALLER: Todd Bateson DESIGNER: Merrimack Engineering PLAN DATE: 8/6/03 SEPTIC TANK Date & Initials INSPECTIONS ❑ Bottom of tank hole has 6" stone base 9/30/03. Mill River 0 1500 gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) 9/30/03. Mill River D Water tightness of tank has been achieved x Visual .Vacuum Test Water held for 24 hrs 9/30/03. Mill River El Inlet tee installed 9/30/03. Mill River D Outlet tee with gas baffle/effluent filter installed 9/30/03. Mill River 20 inch cover to grade installed over outlet of tank if effluent filter 10/7/03 Mill River 0 Hydraulic cement around inlet & outlet Comments: Outlet cemented, not inlet yet. 9/3/0/03. Manhole installed on center of septic tank and outlet side of pump chamber. Pump switched from one on the plan to a Hydromatic SKV50. Contractor had discussed this with designer and Mill River Consulting. Designer to provide pump calculations and specification to Board of Health. Page 1 of 1 D -BOX Date & Initials 10/7/03 Mill River INSPECTIONS El Installed on stable stone base 10/7/03 Mill River D Inlet tee (if pumped or >0.08'/foot) 10/7/03 Mill River D Hydraulic cement around inlet & outlets 10/7/03 Mill River ❑x Observed even distribution ❑ Speed levelers (not required) Comments: SOIL ABSORPTION SYSTEM Date & Initials INSPECTIONS 9/30/03. Mill River 0 Bottom of SAS excavated down to C soil layer 10/7/03 Mill River 0 Title 5 sand installed 10/7/03 Mill River 0 3/4-1 W double washed stone installed 10/7/03 Mill River ❑x 1/8-1/2" (peastone) double washed stone installed 10/7/03 Mill River 0 5 laterals installed and ends sapped a connected to header (and vented if impervious material above) 10/7/03 Mill River FX1 orifices @ 5 & 7 o'clock positions 10/7/03 Mill River M Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: Vent with charcoal filter installed. Page 2 of 2 ' Commonwealth of Massachusetts u Title 5 Official Inspection Form 14 Ha Subsurface Sewage Disposal System Form -Not for Voluntary Assess ents 18 Penni Lane MWN �0 SOWN ANN Property Address Steve Vounessea Owner Owner's Name information is North -Andover MA 01845 12/7/2010 U required for every page. City/Town State Zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do, not use the return key. renin Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover Ma City/Town State 978-475-4786 S115 Telephone Number B. Certification License Number 01810 Zip Code 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 ❑ Fails ee Js Furthe Evaluation by the Local Approving Authority 12/7/2010 Ins ec r 'Sig nature Date 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. ****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. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane Property Address Steve Vounessea Owner's Name North Andover Cityrrown B. Certification (cont.) MA n1RAR 12/7/2010 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane Property Address Steve Vounessea Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont): MA 01845 12/7/2010 State Zip Code -- - Date of Inspection ❑ 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): El broken pipe(s) are replaced -1Y ElN El ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane Property Address Steve Vounessea Owner's Name North Andover MA 01845 12/7/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® 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 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 % day flow t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes Commonwealth of Massachusetts v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not'for Voluntary Assessments ❑ 18 Penni Lane ❑ ❑ Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 12/7/2010 every page. Cityrrown State Zip Code . Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® 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. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 18 Penni Lane Property Address Steve Vounessea Owner Owners Name information is required for North Andover MA 01845 12/7/2010 every page. CityTrown State Zip Code - Date of Inspection C. Checklist 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 recentiy 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? ® ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 550 t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 18 Penni Lane Owner information is required for every page. t5ins • 09/08 Property Address Steve Vounessea Owner's Name North Andover City/Town D. System Information Description: MA State 01845 12/7/2010 Zip Code Date of Inspection Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: ❑ Yes ❑ No Current Date Type of Establishment: Design flow (based on 310 CMR 15.203): Gallonser day Y (gPd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: ❑ Yes ❑ No Current Date Type of Establishment: Design flow (based on 310 CMR 15.203): Gallonser day Y (gPd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane Property Address Steve Vounessea Owner's Name North Andover MA 01845 12/7/2010 Citylrown State Zip Code - Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2008, owner 1500 gallons Measured tank Inspect tank & tees. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts 4 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4�M 18 Penni Lane Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 12/7/2010 every page. City/-rown State Zip Code - Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7 years ago, 10/11/2003, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 15 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall. 3" PVC in house. No leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 05 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x5'x4' Sludge depth: 2" ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 12/7/2010 every page. City/Town State Zip Code - Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" 2" Scum thickness 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 19" How were dimensions determined? Tape Measure 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 tee ok. Depth of liquid at outlet invert. No evidence of leakage. t5ins • 09/08 Grease Trap (locate on site plan): Depth below grade: feet 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: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 18 Penni Lane Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 12/7/2010 every page. City[Town State Zip Code - Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): o.a 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 18 Penni Lane Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 12/7/2010 Date of Inspection 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. No evidence of leakage. No evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump cycled on then off. Alarm has both audible & visual. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 12/7/2010 every page. City/Town State Zip Code Date of Inspection t5ins - 09/08 D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 25' x 40' ❑ 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 evidence 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 ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane Property Address Steve Vounessea Owner's Name North Andover MA 01845 12/7/2010 Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 18 Penni Lane Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 12/7/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately E ^ � t7 c 'L( 10 3, 2, 106 t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 18 Penni Lane Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA 01845 12/7/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de th to hi h round water• 4 If, g g feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/11/2003 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Desiqn plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page.. l5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Penni Lane E. Report Completeness Checklist 01845 12/7/2010 Zip Code Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins • 09/08 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System • Page 17 of 17 Property Address Steve Vounessea Owner Owner's Name information is required for North Andover MA every page. Citylrown State E. Report Completeness Checklist 01845 12/7/2010 Zip Code Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins • 09/08 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 12/6/2010 2:40:07 PM by Karen Hanlon Town of North Andover Class 101 Single Family Size Total 1.24 Acres FY 2011 UB Mailina Index Name/Address VOUNESSEA, MARILYN 18 PENN[ LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 1373$:0 - 18 PENNI LANE 1090416 01 Cycle 01 UB Services Maint. Account No. 1090416 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 1090416 Serial No Status 32772747 a Active Date 10/21/2010 7/22/2010 4/22/2010 1/21/2010 10/22/2009 7/23/2009 4/24/2009 1/23/2009 10/22/2008 7/22/2008 4/23/2008 1/28/2008 10/24/2007 7/20/2007 4/19/2007 1/29/2007 10/25/2006 7/28/2006 5/2/2006 1/24/2006 1/24/2006 10/27/2005 Trouble Code:03 7/26/2005 4/22/2005 2/1/2005 Tax Map # 210-107.D-0058-0000.0 Parcel Id 18594 18 PENNI LANE VOUNESSEA, MARILYN 18 PENNI LANE . N. ANDOVER, MA 01845 Type Loan Number Payor Type Active/Inact. From Occupant Name Active/Inactive Last Billing Date 11/3/2010 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 242.50 /1 Size 0.63 0.63 Location Brand Type 00 b Badger w Water Reading Code Consumption Posted Date 834 a Actual 50 11/12/2010 784 a Actual 98 8/16/2010 686 a Actual 19 5/12/2010 667 a Actual 15 2/12/2010 652 a Actual 51 11/11/2009 601 a Actual 44 8/12/2009 557 a Actual 16 5/13/2009 54.1 a Actual 15 2/10/2009 526 a Actual 92 11/12/2008 434 a Actual 49 8/15/2008 385 a Actual 14 5/19/2008 371 a Actual 15 2/19/2008 356 a Actual 90 11/16/2007 266 a Actual 79 8/15/2007 187 a Actual 14 5/21/2007 173 a Actual 16 2/20/2007 157 a Actual 68 11/16/2006 89 a Actual 68 8/18/2006 21 a Actual 21 5/16/2006 0 n New Meter 0 2/13/2006 3454 r Replacement 19 2/13/2006 3435 a Actual 107 11/9/2005 3328 a Actual 73 8/10/2005 3255 a Actual 14 5/13/2005 3241 a Actual 23 2/15/2005 Size 0.63 0.63 a Commonwealth of Massachusetts = City/Town of System Pumping Record Form 4 t5form4.doc• 06/03 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. A. Facility Information 1. System Location: Leftlamt of house, right front of house, left side of house, right side of house, Left rear of house laht rear of hous left side of building. riaht rear of building under Berk City/Town 2. System Owner: Name (if different from location) City[Town State Vok-) Zip Code State Zip Code Telephone Number B. Pumping Record 1a-7— 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [ 6 If yes, was it cleaned? ❑ Yes ❑ No 5. Con (tion of System: /I i-ou ,vim Q 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loca ' ere contents were disposed: G.L.S. D. owej{ Waste Water 17701 V/./ l o Aaly cA -�D i System Pumping Record • Page 1 of 1 NORTH O ADQATE D WpPP��L SSACHUS� Applicant= Site Location Engineer 1/1 Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 APPLICATION FOR SITE TESTING/INSPECTION �i;I �/�' loxe Test/I nspection Date and Time / CHAIRMAN, BOARD OF HEALTH Fee cv Test No. V S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION : 7q AERATED PPP�'��J SSACHUS� Applicant JIK>'�%� NAME +' ADDRESS TELEPHONE 50 Site Location Engineer NAME ADDRESS TELEPHONE Test/I nspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee � � r Test No. //1017 , S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit.No. BOARD OF HEALTH -�. - NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS MAY 200 3 DATE: ���j -'� �� MAP & PARCEL: 07 Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $200.00 per lot for re airs or upgrades. (If time isnot critical, fee for repairs is $75:00) I GENERAL INFORMATION Qnly. Certified Soil,Evaluators may perform deep hole inspections. 2 Only Mass.: Registered Sanitariansand Professional Engineers can design septic plans: ## 3 At least two deep holes and two_ percolation tests arerequired for each septic system disposal area: Repairs require,a# least two deep:hol Is and at least one percolation test, at the discretion of the BOH representative:. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100,) shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: e " �,9 Check Amount ��%� Check Date: r.. w. ). r a ^ �a 0 } 1.t,^ r. I I ll� I - I , . . . - �. . , , , N --, - ,� , :,- �. 0 is uj A. . W d, Y p NQ y a U z°�° do �' Q' Ott. 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F V - 9 + 9 t `� " i Y N pp x 7s. Y- .-i, ,7 r' fx !v a F` .ya j „� < 01 yYi �. " ! _ I _ F* �,'. ;T r .I, p - S 41' > - f1, 1 ( + - , N wj - !t } R! 's1. ry x ^� b,cq a i a c.. r y �, '. P a1 y _ .� FMy�:d'R" r r r F It y �" t4t�., ._ k s �i j' + 'i i `din - W, I r1 m : EmSn" NW. S y ♦� r'" J- 9:• {)11 i •' r } { yM w 1, - .r .' t t ' : j * f s �xr , '-,. &. 'i4 t . s i r �... x . - , ,*.. r 1k f x i� 1.1 L, r S r� si t riil t ,r .w 6* . AA 4y i.'.3 -'s i,. x ,� x _.' h tT.:w• 3� .. , 5�F , ,r s iE� v '' ' ,r'" .. y' }' "5 'Sect f z'R ' �.a: y �4 r`-«Jx-x,r s. ,a` 4e J7 .�r A .. .. . ..,..t�;. sem,' �' �..�»� a5a Baa *,.- mot _.. _ _ J, ` BOARD OF HEALTH ' .. NORTH ANDOVER MA 01845 - --- - - 978-688-9540:�'' q APPLICATION FOR SOIL TESTS MAY .. 6 2003 DATE: �-�j -'O'?� MAP &PARCEL: 6)7 P LOCATION OF SOIL TESTS: OWNER: 4:,-2%v 6 y Q c! tj jFSstk TEL. NO.: ADDRESS: Lf �6 JAJ tj I (� � ) ENGINEER: TEL. NO.: 6e3_9 6 -,2j) CERTIFIED SOIL EVALUATOR: _,)o p&e- �I�j Intended Use of Land: Residential SubdivisionS' amity ^H a Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No '✓ THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $200.00 per lot for repairs or upgrades. (If time is not critical, fee for repairs is $75.00) GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep -hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area: 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5.. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than F'400') 00') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: c Check Amount: Check Check Dater 5XJ�Q� m N 0 U Jt1S O O W !�� 60 Z N O U a z ' ,6yQ �� � � � N � O Cl vg OVJ 6 W Lul m b O z QQO m Z Q W03 wO U w 0 0 � LUZO 7 ` QN Q Q� ap CO ,;CCC �QW plc O c C) W aZ N fl: Q OWN? C)WZ� �Wj ~ �0 _ Z ZO � W � z aoLU �� ''111,Q Cco X a QE L Q �' t- C/) LL UJ Z Q (� ~ a te ZOQ-1� ` CL =W jW� �cz° tO N W �WOQW L Waw CN to O Z Z CO It. - n 00 O2 O W CO a LU 04 U U 0 U p Z Y NQ c Z w W LU r4WWmO U ` a O C) m ?QW W Wo W' WUO UZ _Qmo� Cf) a S89°45'01 °E ooh 346.90' tiro ---- --- --- o W 30' SETBACK LINE co2 Z PAVED DRIVEWAY- - - - co � Y Wz o 30' SETBACK LINE N co S88 82 P) _ IL 303.48' N e� W E a N_h A y`' 1 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: Le, ,,, LA hAnVIZ_r Owner's Name: • — Owner's Address: Date of Inspection: - 1 — =Z 6 Name of Inspector: lease print) 1"�l.�lJa\ Company Name: o Cst-vN i ce Mailing Address: `4n _4' 0 Cn W Telephone Number. `N --nca' 71-q-1 fob qjh Ci—FN ORT—H A0D0- LER? BOARD OF PlEALTH !MAY A MW k 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 eeds Further Evaluation by the Local Approving Authority ails Inspector's Signature: ALI Date: �" l 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. Title 5 Inspection Form 6/15/2000 page .1, A Page 2 of 11 - NA OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:� n r'1., � e Date of Inspection: F Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: y(% 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: Hk 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): c broken pipes) are replaced obstruction is removed distribution box is leveled or replaced 10 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): ND explain: broken pipe(s) are replaced obstruction is removed - 2 1 Page 3 of 11 4 ` OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: V Owner: Yle'JSD' :> Date of Inspection: 5 — 1 na 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 analysissmustbe attached,to this form. p► 3. Other: 3 a Page 4 of 11 3 O a OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /9 n , A// Owner: !C� p er, Date of Inspection: !S —) D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes N o 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 liquidl'cvel 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 ,s of times pumped . ws' _ 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. liLy portion of a cesspool or privy is within a Zone 1 of a public well. 1� Any portion of a cesspool or privy is within 50 feet of a private water supply well. 0 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.] 6 (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: A To be considered a,large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. , c You must indicate either "yes" or "no" to•each of the following: (The followingcriteria 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 I1 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. 4 ..'r P Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: IS o< n n." Owner: UCLA (1 e ,��c Date of Inspection: JG— 1 — Cb 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 tie' system components pumped;out in the previous two weekO _ Has the system received normal flows in the previous two week period ? L- - 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 ofie iee baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? " _ 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. 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: ,.f%Y1t ifEr Owner: Date of Inspection: S— 1- (nO. FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): .3 Number of bedrooms (actual): DESIGN flow based on 310 CMR d 5.203 (for example: 110 gpd x # of bedrooms): Number of current residents: �F Does residence have a garbage grinder (yes or no): l`rd Is laundry on a separate sewage system (yes or no):/-/# [if yes separate inspection required] Laundry system inspected (yes. or no): _ Seasonal use: (yes of no)�` 7'1, 6 Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): _)�PS Last date of occupancy: 0 cc c. dq III d COMMERCIAL/INDUSTRIAL N A - Type of establishment: Design flow (based on 310 CMR 15.203): gpd 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: -_� ? �/ 4/ 5 %�-'li/r i -t Was system pumped as pato of the inspection (yes or no): _ If yes, volume pumped /,,a. gallons --How was quantity pumped determined? Reason for pi S 7 2 u C 'TYPX'O' F SYSTEM w � Septic tank, distrigution box, soil absotption system r _ Single cesspool Overflow cesspool r 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: ` J Were sewage odors detected when arriving at the site (yes or no). v Page 7 of 11 * ' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS w ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: r)'k t1e V Owner:V40 Date of Inspection: J, — BUILDING SEWER (locate on site plan) Depth below grade: -) 1- , Materials of construction: _1--efit iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): .Yg SEPTIC TANK: 65(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: Sludge depth: '—/ I Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: e) Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: s' How were dimensions determined: /)//' 5/7'c - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �^ Co J/ /% / %-/ 0 -T Owle GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal ' fiber'glass'--Polyethylene.—other (explain): Dimensions: ;;Scum thickness: a '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 8of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: cwn I, bC Owner: Vb"fly � Date of Inspection: 1:�-• I O;-' 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: E galjons. a i 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:'Nif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: /10 C°%" C r 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.): dX Uury �= ,: pis "V PUMP CHAMBER: f ' ' 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.): k d � t r 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: 17 Oenf '(1{ Ve r' Owner: � (f jEE _, Date of Inspection: JG— i -03 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type :leaching pits,,nulnbet: _; ` , a r leaching chambers, number: leaching galleries, number: leaching trenches, number, length: ti 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.): CESSPOOLS: i7(cesspool must be pumped as part of ins pection)(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) w M terials 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 1 ' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS s' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ne rN `. L' Owner: 'Q l Date of Inspection:.— 1�ai SKETCH OF SEWAGE DISPOSAL SYSTEM 1 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. I f 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: t ,.('_ it e Owner: \/-4u.C1G SS Q Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please`indicate (check) all'methods used to determine``the high ground'water'elevation: l'' Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within ISO 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: %-/X5 /:WG I°" P C .6>'1-r -77/Vu 1t %7 77 Je_ uO erE. rI I� PI.•-+-� Gca-MFwA'rjo1.; IS JoT A IJ�,wc� ►�'rY 0 f f 4 E i%40 Summa 54ru S`ISTeH , gT Is A 6EGOGa OF f4F. LaArow A ►.Io a Le V^ -noel app -rw e . qT I uh *f"j?-r coH�oNti►a rte. t d0 �, Rx N t Vcar r, EL -v (Imc--.r) tA 4rrm rAo,,. LAQe __ AS --BUILT PLAN OF SUBSU-RFACE DlSpOSAL SYSTEM 'LOCATED IN K1oR7l-I AµD�/E�, I-'��•� IG> f E1.��� L<tNE AS PREPARED FOR �JTGdC. VOU �.1 ry%�A "rN � 41-7 C7 DATE: I d -IL -o3 SCALE: I': L+a TL se MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS 60 PARK STREET o ANDOVER. MASSACHUSETTS 01610 or TEL (617) 475.3555. 373 sm �oN ,;, _11-luef 1� OT 'fFi PI.�-i•� �.t sr1 c t`o►-Ror.1 �s J a'f A 61+"^►.1'TY 0f'f�lz �i�+Q'sti g e�.L 4'4" KH , tT VP '649 li2;.*TVW d ►V EI.EvAm of OF Trlrc Gwj"i" JA ' f*t111-9 4*HrVW&a tar. u►-�� u5t:p �IYpr�H�'��� 3/ i - I�GtiL. P4�+P ?icul�i 4E�r�c Tic►aL' �6 iJ Ij L LA o E AS SILT PLAN. OF SUBSURMCE. DISPOSAL SYSTEM "LOCATED IN k I OR.TF-I ,D,i-lDU/EQ, e7 PEtJtJi. LO.NE AS PREPARED FOR -'7'fcVt':�-, VDUF.IEyhr-5A DATE: Id -It -o3 SCALE: 1': yp' DmAtL MORA No. 3"52 °? t7 0/37. �W-0 .� TL ss3 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS * LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER. MASSACHUSETTS 01910 or TEL (617) 475-35U. 373 S"l ^4 ( n etE: ->*141,t, P�...� # 15 JOT s%(x,-MH , tT 1s A eL40W of rig La.*rvi AW E6EVAI'f10J VF Ti.l>c 6--1-KIWA *f" rq "mro w&k i4. �uH� I.{�7G'p j�Yl71�N'IA i {G "�I'�JG� �a 1� FE ii 1,.I L �I ELD �I�r) cum LAoe AS BUILT KLAN OF SUBSL)RFACE DISPOSAL SYSTEM "LOCATED IN �1.nrJ o,i.iDr�./EQ, F'�Dh`i.� IPS I�E�.Ni. LONE AS PREPARED FOR -12TtVti:E'. VOU Q rlA DATE: jo-I�-o� TM 0-7 C2 SCALE: I'_ oto' TL �& MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER. MASSACHUSETTS 0110 4 TEL (617) 475-35SS. o1 NORTH A 3ti: 0l, ";i/�D OF HEALTH� TO: FROM: NORTH ANDOVER, MASS BOARD OF HEALTH DESIGN ENGINEER &C V J1f 19 7S— Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at "o '61V /Y / .DK . North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated lVo V it 39' 3 � I LAQ1 P1,904, veloup 144 i ir 00 ro zo sir 4 s w ♦ s JCr o �a o0 d 0a,j '00", B1 3d+7 5' ABSORPTION BED EVD SECTION a J B O Wr--- -- CL 19-3, 0 g In } ' SEPT%c Qr. TANK DISPOSAL SYSTEM PROFILE -w' Mta.ToPsotL Coves. N' WASHMPEASTONS ye -31e 4"PP.RFORA'TE1DO0. "r.F-1' ER(; Iia"WASHED CRUSHEDSTOtAE4i'-I'd . ABSORPrtom AREA J • 20.5 ABsoR'P noH AREA It'llr ABSORPTION BED PLAN :C OBS. H0L -(9 PERC. HOLE PERC RATE PERC TEST 840 5AODY' CLAY • � t� err �•�� t►.lA ,, A.=''61 -o li TEST DATE Tzc-75 &C, Off' DR CK - . � e J tNV-1�16� r� to ear. of r%D lots, o J • 20.5 ABsoR'P noH AREA It'llr ABSORPTION BED PLAN :C OBS. H0L -(9 PERC. HOLE PERC RATE PERC TEST 840 5AODY' CLAY • � t� err �•�� t►.lA ,, A.=''61 -o li TEST DATE Tzc-75 &C, Off'