HomeMy WebLinkAboutMiscellaneous - 181 LACY STREET 4/30/2018 (2)6�
North Andover j3gard tvf Assessors Public Access
Page 1 of 1
North Andover Board of Assessors
0346.
s7Property Record Card
pnrral In •2111/11K iL01161AMA h FV•21111 Cnmmimity • Nnrth Andnver
Location: 181 LACY STREET
Owner Name: ANDERSON, STEVEN
VIRGINIA R ANDERSON
Owner Address: 181 LACY STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 6 - 6 Land Area: 2.42 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2082 sqft
Total Value: 389,700 401,400
Building Value: 172,000 183,700
Land Value: 217,700 217,700
Market Land Value: 217,700
Chapter Land Value:
Price: 0 Sale Date: 01/01/1977
s Length Sale Code: N -NO -OTHER Grantor:
Doc: Book: .01327 Page: 0240
http://csc-ma.us/PROPAPP/display.do?linkld=1707595&town=NandoverPubAcc 12/13/2011 '
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Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - dp not
use the return
key.
26 11
Ibl
t5ins • 11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 Lacey Street
Property Address
Stephen Anderson
Owner's Name
North Andover MA 01845 12/15/2011
Cityrrown
State Zip Code Date of Inspection
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 James Bateson
Name of Inspector
HEALTH DEPARTMENT
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
MA 01810
Cityrrown
State Zip Code
978-475-4786
S115
Telephone Number
License Number
B. Certification
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
❑ qeeds Further Evaluation by the Local Approving Authority
c.�
12/15/2011
Inshto s Signatu 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.
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
=la
Owner
information is
required for
every page.
13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 Lacey Street
Property Address
Stephen Anderson
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845
State Zip Code
12/15/2011
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from B.O.H., install new riser on septic tank over inlet cover, new outlet tee & pipe, new
d -box, inspection from B.O.H., septic system now passes Title 5 Inspection.
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):
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 2 of 17
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVED
OCT 4b` 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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, Left / i ht rear of hous Left/ right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Cityrrown 1 (-� State Zip Code
2. System Owner.
Name
Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system- ❑
❑ Other (describe):
State- aj�de
Telephone Number Imo(
Date Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
5. Conditin of System: C�°k
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L S -Q 1 )_ Lowell Waste Water
—J _
t5form4.doc• 06/03
Date
System Pumping Record • Page 1 of 1
Ell
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: / • MAP: LOT:
INSTALLER: �� � .�l--
DESIGNER
PLAN DATE:
BOH APPROVAL DATE ON PLAN: D
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing allto one building sewer
ElTopography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ gallon tank has been installed
loading
❑ Monolithic tank construction
❑ Watertightness of tank has been achieved by
testing
❑ Inlet tee installed, centered under access port
Comments:
PUMP CHAMBER
Comments:
CONTROL PANEL
Comments:
DISTRIBUTION -BOX
Comments:
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of final grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ gallon Pump Chamber installed
❑ loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Installed on stable stone base
Or H-20 D -Box
Inlet tee (if pumped or >0.087foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
0
Town of North Andover
HEALTH DEPARTMENT
,SSACNISE4
CHECK #: �� DAT /o4,
LOCATION:
H/O NAME:
CONTRACTOR NAME:
5870
I�
Type
of Permit or License: (Check box)
$
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type.
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing ,J
$
❑ Septic Design Approval
. Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
❑
Title 5 Inspector
$
❑
Title 5 Report
$
❑
Other: (Indicate)
$
i
alth Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
a� 13 --//
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
Important: Application is hereby made for a permit to:
When filling out Construct a new on-site sewage disposal system*
forms on the
computer, use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key b— IB u
to move your Repair or replace an existing system component —What? X
cursor - do not
use the return A. Facility Information )
key.
Address or Lot T
ci6y, town G V-2� fi g iI
2.- *TYPE OF §MTIC SYSTEM*: TOWIF NORTH ANDOVER
[� Pump ravity (choose one) HEALTH DEPARTMENT
*** f pump system, attach copy of electrical permit to application***
Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (gavel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. _Owner information
Name�7-
C4frown State Zap Code
Telephone Number
3. installer Information
Name
Address '
4
City/rown
4. Desianer I
Name
Name ofCompON ENTERPRISES, INC
111 Aonu . . .
AIWUVER, MA 01810
State c�+ Zip Code
Telephone Number (Cell Phone # if possible please)
Name of Company
state . Zip Code
Telephone Number (Best # to Reach) -
Application for Disposal System Construction Permit - Page 1 of 2
4
NORTH Application for Septic Disposal System
pConstruction Permit —TOWN OF
ORTH ANDOVER, MA 01845
e_ w•" w
PAGE 2OF2
A. Facility. Information continued....
5. Type of Building: Residential Dwelling or ❑Commercial
B. Agreement
/d—/3—// -
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issu by this Board of Health.
Nam Date I
Applicatio pp ved By: (Board of Health Representative) • .
(Il
Name V Date
plic tin Disappro d for the following reasons:
For Office Use Only:
t�
L Fee Attached. Yes No
2. Project Manager Obligation Form Attached. Yes No
3. Pump S sv tem? Ifso, Attach copy ofElecaical Permit Yes ` No
4. Foundation As -Built. (new construction ronly). Yes �No_
(Same scale as a roved lan I
(SPP P ) n
5. Floor Plans? (new construction only): Yes I No
Application for Disposal System Construction Permit - Page 2 of 2
W.
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the .North Andover licensedinstallerfor the construction for the septic system :for the property at:
(Address of septic system For plans by
Relative to the.application o r_�_O �And dated
(Installer's name)
Dated la -0-11 With revisioi
Z1 o a s ate
I understand the following obligations for management of this project:
1. As the installer, I am .obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the agproved:lilans and the permit on site when any work is
being done.
2. As the installer, .I.must call for any and affinspections: If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall. be applicable.
3.L As the installer, I am required to. have the necessary work completed prior,to the applicable inspections as
indicated below: I understand that requesting an inspection, without completion: of the items in. accordance
my do pane
a. Bottom of Bed = Generally, this is the first (1s inspection unld ' there is a `retaining wall, which
should be don* first. The installer must request the inspection but does not have to be present.
b. Final Construction. Inspection —Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must
be submitted to .the Board of Health, after which installer .calls for an inspection time. Installer must
be present for this inspection. With a 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. wheh*all grading is complete:..Installer does not
have to be on-site.
4. As the installer,' I understand, that only I may perform the work (other than :simple excavation) and I= required
to complete the installation of the system identified inflit attached application: forinstallation:.I ffirther
5.. ,As the:installer, I understand that I
ste 's•
ins involved are also possible.
on=site during theperformance of the following construction,
p•
a. Determination that.the proper elevadon ofthe excavation has been reached.
A Inspection ofdie'sand and stone to be used,
c. Ri 7allnspecdon by Board ofHealth staffor consultant.
d. Installation. oftank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer. I understand that Earn solely responsible for the installation of the system as per the
approved tilans. No instructions by the homeowner, general contractor, or ani other persons shall absolve
me of this obligation.
Undersigned Ilceased Septic. Installer:
(Today's Date)
TO: NORTH ANDOVER, MASS 19 77
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
f o / /-/9c Y S-7North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19
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Town of North Andover
HEALTH DEPARTMENT
,SSACNUSt�
CHECK #: DA
LOCATION: A5/, - J9
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal
❑ Body Art Establishment
❑ Body Art Practitioner
❑ Dumpster
❑ Food Service - Type:
❑ Funeral Directors
❑ Massage Establishment
❑ Massage Practice
❑ Offal (Septic) Hauler
❑ Recreational Camp
❑ Sun tanning
❑ Swimming Pool
❑ Tobacco
❑ TrashlSolid Waste Hauler
❑ Well Construction
SEPTIC Systems
❑ Septic - Soil Testing /% $
❑ Septic sign Approval �6WII $
Septic Disposal Works Construction (DWC) $ J -
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other: (Indicate) $
i
alth Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
� a
is . " •, oc
F • + p
• ', r Town of North Andover
cmu5t4
CHECK #: 4
LOCATION:
H/O NAME:
CONTRACT(
5847
Tempe
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
❑ Title 5 Spector
:tle 5 Report a,/
$
$ —'5* -
❑ Other. (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
v ! fr fT
-rli.-wuQ
Ll
Ll
J, �l
0
El
ri
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do+not
use the return
key.
ILEI
t5ins • 11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 LaceyStreet
Property Address
Steven Anderson'
Owner's Name
North Andover MA 01845 11/29/2011
Cityrrown State Zip Code Date of Inspection
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.
RECEIWI
A. General Information -
��� p �Ull
1. Inspector:
TOWN OF NORTH ANDOVER
Neil James Bateson HEALTH
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
MA
State
S115
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
❑ Needs Further Evaluation by the Local Approving Authority
11/29/2011
Inspecto 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.
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 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
181 Lacey Street
Property Address
Steven Anderson
Owners Name
North Andover MA 01845 11/29/2011
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® 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):
t5ins • 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 181 Lacey Street
Property Address
Steven Anderson
Owner
information is
required for
every page.
E
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
B) System Conditionally Passes (cont.):
MA 01845 11/29/2011
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):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ® N ❑ ND (Explain below):
❑ 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 • 11/10 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
181 Lacey Street
Property Address r
Steven Anderson
Owner's Name
North Andover MA 01845 11/29/2011
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 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 must
be attached to this form.
3. Other:
Install riser for septic tank. Outlet tee in septic tank & pipe to d -box & d -box needs to be replaced
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 • 11/10 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 No
❑ E 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
El Elthe 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 • 11110 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
181 Lacey Street
Property Address
r
Steven Anderson
Owner
Owner's Name
information is
required for
North Andover
MA 01845 11/29/2011
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
❑ E 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
El Elthe 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 • 11110 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 181 Lacey Street
Property Address ~
Steven Anderson
Owner
information is
required for
every page.
Owners Name
North Andover MA 01845 11/29/2011
Cityrrown 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 recently or as part of
this inspection?
®
❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
®
❑
Was the facility or dwelling inspected for signs of sewage back up?
®
❑
Was the site inspected for signs of break out?
®
❑
Were all system components, excluding the SAS, located on site?
®
❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
®
❑
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins • 11/10 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
181 Lacey Street
Property Address
Steven Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 11/29/2011
- -
every page.
0
City(fown
D. System Information
Description:
State Zip Code
Date of Inspection
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)): On well water
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment: .
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes ® No
Current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Owner
information is
required for
every page.
E
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 Lacey Street
Property Address
Steven Anderson
Owner's Name
North Andover MA 01845 11/29/2011
Cityrrown 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 pumpe6as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Date
Pumped 2005, owner
1000
gallons
Measured tank
Inspect tank & tees
® Yes ❑ No
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ m Shared system (yes or no) (if yeas, 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Owner
information is
required for
every page.
E
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 Lacey Street
Property Address r
Steven Anderson
Owner's Name
North Andover
Cityrrown
MA 01845 11/29/2011
state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
34 vears old. 11/12/1977, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 3
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" cast thru wall 3" PVC in house. No leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
2
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: Tx 5'x 4'
Sludge depth:
8"
❑ Yes ❑ No
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 9 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
181 Lacey Street
Property Address
Steven Anderson
Owner's Name
North Andover MA 01845 11/29/2011
Citylrown 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
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
24"
8"
8m
10"
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 baffle ok. Outlet baffle corroded on top. Needs to be
replaced with tee. Tank is 2' deep, needs riser. Depth of liquid above outlet invert. Found pipe to d -
box pitch towards tank. Needs to be replaced. No evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
❑ fiberglass
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:
feet
❑ polyethylene ❑ other (explain):
Date
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 Lacey Street
Property Address
Steven Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 11/29/2011
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.):
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: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
l5ins • 11/10 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
181 Lacey Street
Property Address
Steven Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 11/29/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert -1/2
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.):
Liquid level in d -box below outlet inverts. Evidence of leakage. D -Box has corrosion holes. Needs to
be replaced. Evidence of solid carryover, pumped d -box to clean.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 11/10 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
' 181 Lacey Street
Property Address
Steven Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 11/29/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
❑ leaching trenches
number, length:
® leaching fields
number, dimensions: 1 field 20'x 45'
❑ overflow cesspool
number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer ;
.Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'< 181 Lacey Street
11/29/2011
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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Property Address
Steven Anderson
Owner
Owner's Name
information is
required for
North Andover MA 01845
every page.
Cityrrown State Zip Code
11/29/2011
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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Owner
information is
required for
every page.
Is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 Lacey Street
Property Address
Steven Anderson
Owners Name
North Andover
MA 01845 11/29/2011
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
vc.
wa�
PcZ� ;k
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
181 Lacey Street
Property Address
Steven Anderson
Owner Owner's Name
information is
required for North Andover MA 01845
every page. City/Town State Zip Code
E#3
D. System Information (cont.)
Site Exam:
11129/2011
Date of Inspection
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >4
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: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
® Accessed USGS database - explain:
Essex County Soil Map
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet # 37, Canton Soil, Water > 6' Deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M . 181 Lacey Street
Property Address
Steven Anderson
Owner
information is
required for
every page.
Owner's Name
North Andover
MA 01845
11/29/2011
Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® 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
t5ins • 11/10 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
r
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, Leff. t rear os?Left / right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Cityrrown l ` State V` Zip Code
2. System Owner.
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
44QIAC�Y\
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
State
Telephone Number
— 2. Quantity Pumped:
D-ge-ptic Tank
Zip Code
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes [R'iV If yes, was it cleaned? ❑ Yes ❑ No
5. Condition pf,System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatiogAtlWe contents were disposed:
G.I„S _ Lowell Waste Water
t5form4.doc• 06/03
61-D9
Date
System Pumping Record . Page 1 of 1
ADDRESs
ol
OCT 0 7 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMIENT
S YS T'E
J311:2�-X— 0,11Z 1-ia�
DATT. OF PVMpqNo:
QOA N 71 T y pUtMpCC,
rVK� ON 6-0 V �rl
GOOD
KQQT3
"CUMS SOLID&L F-AvC KPI eL 0 K UN
$OL rD C -A XA YQ nA pLoocBc)
ONER EXPL,�IN
17")
0
z -,r
WELL DATABASE
ACL OF W`EL r.: WE DIP LLLE.R:
zI r. PERLti ,T: WELL LOCATION:
-WELL. PER= DATs:- DEPTIE' OF WELL:
L: �
- --TYPE OF WELL_ a_ DRILLED b. G c. L Nvv OWN
=E: CF WATT BakRING RG CK -
WA= ANAT-Y= DA=-
K-WA=ANAT-Y=DA.T- -� `GHN1AiNCALNESz:. Y N
E`IGEIRCN Y – N OT= ccN A NfNANL Ts: it N
r.'
7 -Y -ELL. DAT.;kEAM
ADDRESS:
AGE OF 7 E=: VY LLL D=LEI
WELL PE���ffI T: WELL L O.CATION:
WILL ==DATE: DEEI"HE OF 7y
TYPE OF WELL: a-. DRILLED b. DU c _ USI FK OWN
TYPE OF WATER BEARING ROCK:
WATER AN ?.LYSIS DATE: HIGH YfANGANES1: Y N
I-EGH SON: Y N OT= CONTAbMENANTS: Y N
U v
Commonwealth of Massachusetts K, ME
City/Town of
System Pumping Record NOV 12'2012
Form 4 TOWN OF NORTH ANDOVER
MALTH DEPARTMENT
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, Left /f igh rear of horns , Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town State
2. * System Owner:
�de�so�
Name
Address (if different from location)
City/Town
Zip Code
StateZip Code
//
Cog OC lg�s
Telephone Number J
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) 2//Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatiga-whkre contents were disposed:
Gallonib O 0
❑ Tight Tank
No If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Lowell Waste Water
1
ule Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
APP4rOV - -_
Dsie:�-�� -15-77
(Zl,--A Built Submitted
NORTH ANDOVER BOJM OF PEAL TH
r
!NS Tj.LLA`ITON CH_X- K LIST
BISf�t'P?OVA `__-_._.-..-.�-._...__.._...
Date: __ EXCAVATION OK
Reason:
Check: Lot location, dimensions of system, location in regard to
Percolation tests, depth of system, tater table
el�. Distance to Wetland Areas, Drains, Street & House
_ , Drainage Easement and Wells.
Water Line Location
Iv*o PVC Pipe
t
Septic Tank - Tees, Cement -Pipe to Tank_ Joints on both side of Tank.
X.Distribution Box - No cracks in box or cover, all lines flow ec_uaJ ly from box.
Leach Fields - Dimensions
>, Stone Depths, Capped, ends, Clean double-i-mshed stone
8 Leach Pits - Dimensions, Depth of Stone, Splash pac,tees, Cement -pipe to tank -
joints on both sides of tank, Clean double -washed stone
9 No Garbage Disposals
t�0= Final Grading 4 barricadin of sub -surface ce systems
ay ,
NORTH ANDOVER P /
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
I. General Information
Reg. 2.5 The submitted plan must show as a minimum:
(a)T'the lot to be served
(b)�,location and dimensions of the system (including
reserve area)
(c)�`I`design calculations
(d)E�.calculations showing required leaching area
(e)��,existing and proposed contours
(f)of, lo cat nn and log of deep observation holes -
.�� distance to ties
glocatLon and results of percolation tests -
r distance to'ties
(M Orlocation of any wet areas within 100' of the
sewage disposal system or disclaimer
(i)_
i)'surface and subsurface drains within 100' of
the sewage disposal system or disclaimer
Q) ) location of any drainage easements within.= ---
100' of the sewage disposal system or disclaimed
(k Oriknown sources of water supply within_.' of
the sewage disposal system orrrdsc_lamer
(1)6��location of any proposed well `to serve the lot
(m)*',location of water lines on the property
maximum ground water elevation in the area of
the sewage disposal system
\.
( o) -= arofile of the system
P Y
(p)' rio PVC is to be used in construction
(q),,s'location of benchmark
(r);, -plan must be prepared by a Professional Engineer
or other professional authorized by law to prepare
such plans.
` II. Garbage Disposers (-y-
III. Septic Tanks
Reg. 6.1 (a) Capacities - 150% of flow
Reg. 6.7�!b) Water table
Reg. 6.8_�r(c) Tees
Reg. 6.9 '11 (d) Depth of tees
Reg. 6.12 '(e) Access
Reg. 6.18 C r ( f ) Pumping
(g) Cleanout
IV. Pumps
Reg. 9.1 (a) Approval
Reg. 9.6 (b) Stand-by power
D
V. Distribution Boxes
Reg. 10.2 (a)OfISlope greater than 0.08
Reg. 10.4 (b)(f' Sump
VI. Leaching Pits
Leaching pits are preferred where the installation is
possible.
Reg. 11.2 (a) Calculations of leaching area (minimum 500 S.F.)
Reg. 11.4 (b) Spacing
Reg. 11.10 (c) Surface drainage 2%
Reg. 11.11 (d) Cover material
r
VII.
Leaching Fields
Reg.
15.1
(a J Greater than
20
minutes/inch
Reg.
15.1
(b)A= Area (minimum
900
S.F.)
Reg.
15.4
(c)®EP Construction
of
field
Reg.
15.8
W ,,i�Surface drainage
2%
IX.
Downhill Slope
(a) Slope y/x =
(to
be shown) Q�
(b) y/x X 150 =
(to
be shown)
SOIL PROFILE & PERCOLATION TEST DATA
ey a'
Town/Ci y No.&Street Lot No.
Loc . / Subdiv . Plan owner Aa'
Investigato �&. ,�/Q Observer
SOIL PROFILES -DATE
1' Elfev, 2. Elev._ 3' Elev. 4'Elev.
0 77 0 0 0
I\�
3
�4
J 5
C 6
7
0
2
3
4
6
�. 7
9
2
3
4
5
6
7
M
9
7
� a
9
10 10 I ---I 10 1 _� 10
Benchmark Location
Elevation Datum
Percolation Tests -Date
`-7"//9 77
Pit Number 1 2 3 4 5
Start Saturation -
Soak -Mins.
Start Test -Time
Drop of 3" -Time
DroD of 6" -Time
Mins.lst 3"Dro
Mins.2nd 3"Dro
Notes & Sketches on Back \'"Frank C. Gelinas & Associates, North And.
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