Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 190 DALE STREET 4/30/2018
190 DALE STREET 210/037.6-0005-0000.0 ' 1 f i i , SEPTI_ S_Y_S�.E.M_�N.�.I9.4L.AZ.�_QN. • IS THE INSTALLER LICENSED? YES NO 'TYPE OF CONSTRUCTION: NEW <RERAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF..APPROVAL YES NO (FROM FORM U) ,ISSUANCE OF DWC PERMIT YES NO DWC PERMIT N0. INSTALLER: J1Al Zt),41501) BEGIN INSPECTION YE NO: STiNC 3�z9143 EXCAVATION . INSRECTION: NEEDED: PASSED / BY- --- - . CONSTRUCTION INSPECTION: NEEDED: --:D- -pox - HY-D AL>L c6,M& T AS BUILT PLAN SATISFACTORY: i APPROVAL TO BACKFILL: DATE: BY -- C -FINAL . GRADING APPROVAL: DATEBY _ ON APPROVAL: DATE:_l > _BY •- FINAL CONSTRUCTI , 1 NORTH ANDOVER HEALTH DEPARTMENT 27 Charles Street a North Andover, MA 01845 Tel. 978 688-9540 a Fax: 978 688-9542 email: healthdept@townofnorthandover.com Compnvestigation/Ins ecti n Report OWNER ADDRESS of a DATE pL4-G 1 S C-f" 1 I--/ e :E- 4 Rev.6/04 INSPE TOR N �yy N f.�yrf'7 � v t u, C. ar M. r s+'— _A� T3u LLT` Ti� c BLbCl- COP— A --S•T'M��},_cam -- -- �,�,3� 3�,0, L - BoX fuD TTL ( 0 &BuIJ�T• t2fVA-lJ0ki5,3 ToP r',UUT J, (As suvif5D) IDD.DO �1"� SCH•�-lo���•c. I>�v 1J.1 � p•Bax ��b,�z ply p_20x -Q0,27 It uD Tl�+ Z; 5,73 W N uu 0 �xlsT" LE�cI•ll�� 72�C �S 19.5 n[Sj; C6�JC, ID-BOX, L_ C xIST jS-00 6AJ.,,, Come, t-,E:pTiC TAIJ V— srrtET- - 130' 1DALL S T" AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEMLOCATEDIN MORTH- AUDOVER , MASS , AS PREPARED FOR_ BAYBAM K DATE : APRIL ) , )qq3 SCALE: I"=-q0` `WI RO DALE' STRUT LOT'S TM. -3-7-B PAR. MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS: 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 9 TEL. (6,*) 475-3555, 373.5721 ® NorEs sorL F /, qLL F/LG TO � CGEA.V S�4N0 OR GR.4l!EG .SS4li/it/G A j �Pr Sol Y FSG PERCOLAT/ON BATE OF LES Tf1��/D.Q EQU.4G Tb 2.t!/rt///�/C� Grzr�VEL RAT " AFTER BEt/G PLACEO ANO Pi9DPE/�LY COrt1P.9CTEo• �Z' 2 Nl1 SII 2. .QLL SANE TD BE N/.4SHE0 AS NECESS.4Ry 7t�,QE,NOVEF/.f/ES rAUt $Auty c3. TH,CS .SYSTEti1 /Or 'W,;- OES/6.1/EO Fd.9 T.vEGfSEOF.�G.O•YB4GE GR/NO�� qo' -M_2' S oo,Uovc7ED 10-q-q Z 4. .9Eit�lOvE.4LG �voSoiG,•�oaxs,quo �wBSo�G fr���c� wiry wrT,tlESSED SPEC/F/EO F/LG lC//T.�!//V /O', SSV-57EiL/• 'U sAi�Dy STAIZQ, HEACTH A6EEj , I pg ,3 COVER 40'47-Eft14L AVER T,�/6 51',3TE�tq �5.'lALG f�E FLEE OF �o wgTE(Lc�to�" LA•YGE,.3'Td�l/ES, y/.9.so�t/.QY,�s-TU�YI�.S aR H/.�ISTE C'acCsTiQGL'T/o�c/ E�T;S.H•W.T:�7g'� /N/ITF�/•9L. Tf/E ToP 9'".Sf/.4LL B�La4�E0.4ivO�R�•4CE 3EEOEO- iYJiOC///it/EiPY lf/N/C// '-�GCsy aw O/JTl/�YB T•�B ,1•�-� .9L/G/t/iL1Eif/T OF TME �/�E.S /�t/TfIE O/S��-SAL .4�?E.4 D//-4LG �'olL Drt 1 ft .NOT BE AGGOK/EO• �WF STMT-4 ALL, APPLICAa(.E eEDVI(rHffJ SOF��D Th TD�J�I �" ,110�h}�AT� Euul0o�cF�Eu,AL conn T S� AUIJov5F_ PoAW 6F HFACrH MIu(Fjvtj Fe)e THE SUef,)p ACC [)ISPoSwC, 0F' 9/lLWrMZy SEtAGE Tb RE. Cot�l�r� W iTtt. 7. ACC, P►PI rC To I Scr-ir Qvc �1 o Rv, , J_0 93. Tw2je-t4 "'h�' rub To gr- 10' r,Erwrr_u ExcAVWna-( 91b6 Aus, 004 S,f (rf 3TB PATI.s) CALNLA-00US: - Df-:�SlGk,( FLotJ fS FoL 3 BALMS, cl6SG.P,A -RD, - 1EACNl�cC CA PAGrT-y �oP- C46141,u4 TFCJ.(CtNES 3.0' wi 61= F IZ'' E'rf:rcrjVF_ DEPTH A-r PEC?G FAIr--'= Z MIu/W = SI DEWAGC, CAPAd d'/=Z•o S.FIFT x Z•S6P0 S.F. = S:o (AL/F-r. goTTNI 6gPAef y=3,o s.F/FT" x ),06AU9,F.= J49SGA(,13,© 6Al,1rr- GZ F of -l_E.ce,-t P_5aD- - VSE Z 'I-2f"a�CtFCS d 5'0' TO PP-6;prlbE S'oo S, F. P"►IAu- IEACHW,� AZE4 AS PF-P- 7ZXJ. .( 2l5'QulrcEt1E"urS, BolT611 OF -rpritcblcs 7T%) e_'c- do bFcpf✓a 7r►-!f9_( 2•5 p`\�� FES"(` gECvk) EXiSTI�rCj Gf1ap� o.L-r UAHtt,l Sr�E c9� � "771E ESTI I.1 r�7E.p JEA�D�lAL 1-I I CaF-I ltili�l�� T���� �S,H,wZ' O Q C411Tf?�1GTb(Z l�o VEIZIry LU6AroL4 OFA)_(y E,rISTL'f4 V_ com (.?/�Ot~�Geov�rD VTit-i-mg Peioe TD CoAjSr¢0677a-u . It P,CCAerT r�l� 7acucNES _�PFOP"3-HvcE e ua r �. Slv PE. A S Al-1 EGESS�12�� 1✓x�sT � ►Is��leo APP26X, 6oCA7701.f or ExrSTW4 CC•AC14Iz16T FAC1 -\( -(SrZE � TYPE uw)F 2f lrr`(Fl�) t ; APRET2o� � ST2EE 130 PFOR 1Soo ��A/ Cotre. SEPT►C V14I IG D�� . r , rr RrF A PP26x. t vwn orr.t of - ToZEQ � LIC0 I500 GAL. CouC O� _ sEPn -i-Au1C, SUBG0RrACE DISPOSAL SysrD-A UORTf ANDOVER, MASS . BAY BAUK ASE: t"-�►o" DATE: tEdFHB02, (Rl2 �L „ MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL.(508)475-3555, 373-5721 FAX(508)475-1448 ,►ORTIy ?Ofa', .° BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 AcHUSEtty NORTH ANDOVER, MASS. 01845 Ext. 32 April 7, 1993 To Whom It May Concern: The septic system located at 190 Dale Street, North Andover has been repaired according to the plans submitted by Merrimack Engineering and inspected by the North Andover Board of Health. Sandra Starr Health Agent MERRIMACK ENGINEERING SERVICES INC. �� 0 UEUTEM OF �GD�a[�SEMAL Engineers • Surveyors III, Planners 66 Park Street a' !! ANDOVER, MASSACHUSETTS 01810 DATE JOB NO. 'af5 475-3555 ATTENTION fy TO SW�ti/ SIAM- BISH M 0�N�}&TH RE: �qd TOcv)l! 14AU -120 MAIC.( ST— I 1`. �'�P71 G 19Z I J 00771 A).JWV151Z , tl A. 010 _ WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items: ElShop drawings 8'-Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION � THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ks requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO SIGNED: PRODUCT 240.2 a Inc,smmn,Mea.01471. If enclosures are not as noted, kindly notify us at once. I Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH ' NORTN� 19 ' pt 4t�ao ,aa 4'C KI 3? a t. - -• OL O p DISPOSAL WORKS CONSTRUCTION PERMIT SA Us. applicant �`'' TELEPHONE NAME ADDRESS Site Location G =� or Repair (individual Soil Absorption ' Permission is hereby granted to Construct ( � royal S.S. No. ��7 Sewage Disposal System as shown on the Design App CHAIRM N,BOARD OF HEALTH / D.W.C. No. Fee l�J Town of North Andover, Massachusetts Form No.2 NORTN BOARD OF HEALTH q o � 9 i�o' DESIGN APPROVAL FOR SSAC14USEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant. Test No, Site Location /qD UaLC.. Ab- Reference Plans and Specs. ENGINEER DESIGN 0 VATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee—bo Site System Permit No. T ISI MIRIMACK ENGINEERING SERVICES, INC, PROFE.SMOW ENG VEERS 0 LAND SURVEYORS 0 PU4NNERS db-PMK 04it_s ANDOVER, 01816-«�-(SOB 475-3555, 373-5721 + FAX(508)475-1448 January 4 , 1993 Ms . Pam Josh idn BayBank (� n #7 New Efl§tA1d' EXeGUtive Park Asset Deperment, 4th :Floor Burl ingten, -® I4 01803 R S otic. pair :• #190 Dale Street 149051 over# .Massachusetts Dear Ms.- Johttsonb` Please find enclosied, copies of the septic repair plan for the . subject Litt, This i nth ttitl on"- has been submitted to the Town of North Andover Health Dtportment for review. pl#WS . �. 1 K fi n `�tn �1 +� o13 . i tdsre T"anu T v ' JAN tlo " $ y93 M � Vendor tri � UW Please reVi-ewlthe, Onclosed information and feel free to contact me should'}YO,0'« hdve'.,any �uestiot�s . or comments . j Vpry truly yours , -MERRIMACK ENGINEERING SERVICES 'i� Godi n Project Manager .trlt't' Ysb PAY BY OREO COMPANY 13 enc (t t Coo comet About Chargee! FAY•. - . - i. i QCT I !1� III � I I i MERRIMACK ENGINEERING SERVICES, INC, PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL.(508)475-3555, 373-5721 FAX(508)475-1448 October 15 , 1992 Ms . Pam Johnson \ BayBank #7 New England Executive Park Asset Department, 4th Floor Burlington , MA 01803 RE: Septic Repair: - #190 Dale Street Forth Andover , Massachusetts Dear Ms . Johnson : As per your request our firm has investigated the apparent septic failure at the subject location . Research of the Town of North Andover Board of Health files was per-Formed in order to obtain any existing plans or documentation regarding the existing septic system. No plans were found on record , however , an owner ' s questionnaire and an inspection form from a Town Board of Health inspection , conducted in 1986 , was obtained . These documents provided minimal information . Copies of these forms are enclosed for your file . An on site inspection was then conducted in order to determine the approximate location and condition of the existing septic system. Based on surface land features , there appears to be a septic tank of unknown size in the front yard area , which then leads to a leaching area in the southeasterly corner of the front yard. Due to lack of recent use of the septic system , no sewage effluent was observed breaking out of the ground surface . However, it was evident that breakout had occured at some time when the house was occupied and the system was in operation . This evidence of breakout indicates that the existing septic system is most likely near or at the point of failure . On October 9 , 1992 , our Firm, in the presence of the Town of North Andover Board of Health Agent , Sandra Starr, conducted subsurface soil investigation in order to determine a suitable location for a replacement subsurface disposal system. Using a backhoe , a deep observation test hole was excavated approximately 25 feet behind the existing house in the rear yard . The tests results indicate that the existing soil conditions in this test area are suitable to support a subsurface disposal system. The test results are enclosed . If a replacement system were to be constructed , we would recommend the following as a minimum : Ms . Johnson Page Two October 15 , 1992 1 . Anew 1 ,500 gallon concrete septic tank to be installed in or near the location of the existing septic tank in the front yard. 2 . Two neer leaching trenches to be constructed in the soil testing area in the rear yard to accommodate a design flow for three bedrooms at 165 gal /day = 495 gal /day Effective Depth = 12 " Below Invert Effective Width = 36 " Length = 31 ' Total Length for Two Trenches = 62 ' Total Capacity = 496 gal /day Trench Spacing = 10 ' Between Excavation Sidewalls 3 . Bottom of trenches to be no deeper than 2 . 5 feet below existing grade on uphill side of trench in order to maintain 4 ' above estimated seasonal high water table . 4. Topsoil and subsoil to be excavated and replaced with sand or gravel fill within 10 feet of leaching area . 5. The trenches should be dug parallel to and at least 20 ' from the existing foundation . E . All applicable Requirements of the Commonwealth of Massachusetts State Environmental Code Title V and the Town of North Andover Board of Health Minimum Requirements for the subsurface disposal of sanitary sewage should be complied with . Please review the enclosed information and recommendations and feel free to contact me at this office if you have questions or comments or if you desire any further plans or specifications for the project. Very truly yours , MERRIMACK ENGINEERING SERVICES Les Godin Project manager sb enc cc: Sandy Starr MJERRIMACK ENGINEERING SERVICES,INC. 66 PARK STREET • ANDOVER,MASSACHUSETTS 01810 SOIL TEST RESULTS FOR SEPTIC REPAIR #190 Dale Street - North Andover , Massachusetts Tests Conducted 10/9/92 by Merrimack Engineering Services and Witnessed by Sandra Starr Health Agent for the Town of North Andover Test Hole #1 0 "- 18 " Topsoil and Subsoil 18 "-42 " Gravel 42 "-54 " Gray Sand 54"-90" Sandy Till 90"- 108 " Silty Sandy w/ Clay No Ground Water Observed Estimated Seasonal High Water Table @ 78 " Note : -Evidence of Ancient Leaching System Encounted During Excavation Percolation Test #1 Percolation Rate = Less than 2 min/in MERRIMACK ENGINEERING SERVICES,INC. - 66 PARK STREET - ANDOVER,MASSACHUSETTS 01810 1 URTAi,IiGA Mop_-1 4k;aovi5Z �BoAi2D or i46�(; t Fig WATERSHED RESIDENTS QUESTIONNAIRE 1. Name 2. Street Address ��? ' L �� S,r 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool septic tank and leaching area ❑ connection to municipal,sewer ❑ other (describe) ❑ do not know 5. Are,the plans (drawings) for your sewage disposal system on file with the Board of Health? yes ❑ no ❑ do not know 6. Hovwold is your sewage disposal system? ❑ 0-5 years 1016-10 years ❑ 11-20 years over 20 years 7., do. not know 7. Has your sew 0' _disposal system been rebuilt or repaired? ❑ yes no do not know If yes, approximately how long ago? years. What was done? 8. Hord frequently is your sewage disposal system pumped out? F7 annually yf ever -4 years _ every -i0 years ! over 10 years Elnever 9. Have you had any problems with your sewage disposal system? ❑ yes 1p�no If yes, what problems? ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your seyvage disposal system? washing machine ✓✓ dishwasher ✓ garbage disposal dehumidifier drain sump pump toilet roof/pavement drains showerlbathtub ✓ 11. Please state the brand and tyVe (liquid or powder) of detergent you use for: dishwasher clotheswasher 12-< - 12. e12. Does your property have a lawn? tai' yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre Cd' '/z acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres . 13. How often do you fertilize your lawn? No. of applications per year Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ... • . .� - i - __ _.. .r......L........7 1.., -. ...a.�..ccinr o� dor l�C!`aTP �nntra�tnr- OBTAWEL)' Fizor�' MgVlt l4k4ov5Z BOARD Dr 14t5Ai-n-i F+6�-S SEPTIC SYSTEM INSPECTION FORM ADDRESS DATE INSPECTED eEv PROPERLY FUNCTIONING? N WEATHER CONDITIONS COMMENTS : WATER OLALI y TES tb ? IZESOLTSI DYE TEST PERFORMED? Y N DATE? SKETCH: WATERSHED RESIDEfNTS QUESTIONNAIRE 1. Name �`�G' 1 2. Street Address 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. AAreAhe plans (drawings) for your sewage disposal system on file with the Board of Health? Y yes ❑ no ❑ do not know 6. Howold is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years over 20 years ❑ do not know 7. Has your sewaag�disposal system been rebuilt or repaired? ❑ yes Z no ❑ do not know If yes, approximately how long ago? years. What was done? 8. ;7every (frequently is your sewage disposal system pumped out? El annually 2�4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes 5Kno If yes, what problems? ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your se}a�age disposal system? washing machine �`// dishwasher ✓ garbage disposal dehumidifier drain sump pump toilet cJ roof/pavement drains shower/bathtub 0---' 11. Please state the brand and tY e (liquid or powder) of detergent you use for: dishwasher �r �'�'� '/�cul?�,� clotheswasher AeM -CcJQC� 12. Does your property have a lawn? yes ❑ no If yes, approximately what size? � ❑ less than 1/4 acre El 1/4 acre L7� '//-/z acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? No. of applications per year O Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: 1 ❑ Check here if your lawn is maintained by a professional landscape contractor. SEPTIC SYSTEM INSPECTION FORM ADDRESS 90 b�A,' O- DATE INSPECTED %"dlo- PROPERLY FUNCTIONING? N WEATHER CONDITIONS COMMENTS: a WATER OVALI T Y TES i Fb '? JZESOLTS? DYE TEST PERFORMED? Y N DATE? SKETCH: vVAT'1'___1ZSHED RA-ES-11DE,NITS QUESTIONNAIRE 2. Street Address 3. How many members are in your household? 7 3 4. What type of sewage disposal system do you have? i _cesspool =kJ1� septic tank and leaching area connection to municipal sewer other (describe) do not know 5. A e.Ahe plans (drawings) for your sewage disposal system on file with the Board of Health? yes ❑ no ❑ do not know 6. '10 .old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years over 20 years ❑ do not know 7. Has your sewaag"isposal system been rebuilt or repaired? ❑ yes [K no ❑ do not know If yes, approximately how long ago? years. What was done? 6. l�frequently is your sewage disposal system pumped out? ❑ annually ever32 4 years ❑ every 5-10 years ❑ over 10 years ❑ never 1 9. i:ve you had any problems with your sewage disposal system? ❑ yes Ly' no xf yes, what problems? ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. flow many of each appliance are connected to your se}Kage disposal system? -tvashing machine ✓✓ dishwasher. ✓ garbage disposal dehumidifier drain sump pump toilet re f/pavement drains shower/bathtub ✓ 11. "lease state the brand and ty a (liquid or powder) of detergent you use for: �/Q�C-'o� dis,,Evasher um� clotheswasher AeM h_7AM mc',f—' 44,>4C1E'"e— 12. Does your property have a lawn? V--yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre 19/1/1 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. flow often do you fertilize your lawn? No. of applications, per year Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor. AS BuILr' T�" � A 8 G D _-D-Box SIS • D �4o�aa� S'P. AS Bw-l'- 5Lewriioki!g Top riji rU (Ass mab) IL100-Do SC H.40 P.\f•C- Iuv I 1 @ p•BoX 10,� Z „ p vm I)-Box q0,27 r� i� �� ►� " C luctTre#Z i .00 w W (vNw, UJ �XISr ZEAC�UUC� lLF-�►C ES 13'6.C. 19.5 EXIST. CD�l1C,l�-BOX � B HSEVIgO L_•D come• stpnc TAW l= sr2gET' AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NORTH- AKADOVER , .MASS . AS PREPARED FOR- BAYBA N K DATE : APRIL ) , )qq3 SCALE: 1"'-1qO� #I q0 DA E7 SMEm:7 LoTr9 TM. -37-B PAR. -57 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS: iuL 1. 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 0 TEL. (5a0) 475-3555, 373-5721 OFFICE WILMINGTON PLAT (508)664-3101 CUSTOMER'S COPY (508)658-3601 HEFFRON MATERIALS A DIVISION OF HEFFRON ASPHALT CORP. PLANT:SALEM ST.RT 62 WILMINGTON,MASS.01887 P.O./JOB NO. DATE + • ti �^ 7 SOLD TO (,1' DELIVER€115'T6r 1 THIS COMPAN fQOT RESPONSIBLE OTHER FOR ANY DELI. S BEY D E qmB SCREENED VWH S IE SfNKL SAND N F K AV PEA1 STONE N ST O gfeseiD ;,.x- A D t SA i . `I *By signing, you acknowledge your TRUCK NO. responsibility regarding the GVW laws set forth by the DOT! f 1 GROSS r /\ CS PRICE TARE � TAX NET TOTAL 1 DRIVER ` a, \ SWORN WEIGHER ; REC'DBY No HO®8642 BRADY BUSINESS FORMS LOWELL MA 0I852 206552�K f FILE#03/698A 107 Forest St. Middleton,MA 01949 (508)774-2772 CIIAIAVJF SEPTIC & DRAIN SERVICE ? 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: PROPERTY ADDRESS: 196 �. �e <zL Al. Amjove r" �-I!} ADDRESS OF OWNER: Sam E (if different) DATE OF INSPECTION: 1 (� l�-f►4 rc� j 4R8 NAME OF INSPECTOR: •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • 105 Forest St. FILE#Qf,31(,?YA Middleton,MA 01949 (508) 774-2772 C'11AVA ArArw SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Garbic.k Address of Owner: Date of Inspection: IG HArch III?% (If different) sG�►'he. Name of Inspector: 7hom►rs T• Ua`to I am a DEP approved system inspetor pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: Currier <_e4, t-Drain r Mailing Address: j[S7 55rGS11 S Telephone Number: (97$) '77Y-277 , CERTIFICATION STATEMENT I ceniry 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sev,•age disposal systems. The system: Passes Conditionally Passes feeds Further E%aluat on By the Local Approving AuthonN Fads Inspector's Signature: AG,4 Date: _� /1/4R �9 g V- V The S\-stem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow- of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check ® �, C, or D: Aj SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 8) SYSTEM CONDITIONALLY PASSES: _y One or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, upon _ completion of the replacement or repair, as approved by the Board of Health, will pass. _ Indicate yes,no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 0{/25/97) Paye 1 of to DEP on the World Wide Web' http./rwww mapnet.state ma.us/der. Printed on Recycled Paoer • FILE# 3/69SOA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f ,( CERTIFICATION (continued) Property Address: /90 D!e 6 Owner: ISQrb i c k Inspection Date of :/l�Ilf-oz 98. BI SYSTEM CONDITIONALLY PASSES !continued, Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): Vbroken pipe(s) are replaced oostruct!on is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER •+ ,W////HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or priv is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'v'well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Days 2 of 20 FILE# 3 69�� SUBSURFACE SEWAGE DISPOSAL SISTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �9� e S� Owner: &0.r 1 Ck– Date of Inspection: IL D) SYSTEM FAILS: to us: indicate ether "Yes" or "No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The oat for this determination is identified.below. The Board of Health should be contacted to determine what will be necessary to co"e- the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS c- cesspool. Static liquid level in the distribution boa 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 flov.. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsi. Number of times pumped — Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. IYA Any porton of a cesspool or privy is within 100 feet of a surface water suppiv or tributary to a surface water supply. /.ILS Any ponion of a cesspool or privy is within a Zone I of a public well. _ ILA Any portion of a cesspool or privy is within 50 feet of a private water supply well. Am, pon on of a cesspool or privy, is less than 100 feet but greater than 50 feet from a private water supply well with ro acceptable water quality analysis. If the well has been analyzed to be acceptable, attach cop". of well water analysis for cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EI LARGE SYSTEM FAILS: u must indicate ether "Y ' or "No" as to each of the following: The following crit ria appIv to large systems in addition to the criteria above: The system se es a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ubhc healt and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply �'' t system is within 200 feet of a tributary to a surface drinking water supply _ the s tem is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a A public ater supply well) .rF The4owner or operator of any uch system shall bring the system and facility into full compliance with the groundwater treatment program re�utrements of 314 CMR 5.00 nd 6.00. Please consult the local regional office of the Department for further information. (revimed 04/2S/97) Pape 3 of 10 ,.r FILE# 03/G 9?,4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l� �e S t Owner: GQrbick Date of Inspection: 16 wrn Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with'N;A. _ The facilit, or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. •. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facilm owner land occupants, if different from owner were provided with information on the proper maintenance of Sub-Surface Disposal Svstem. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302,3)(b)J i i (revised 04/25/97) Page 4 of 10 j FILE# 3/694 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C \\ SYSTEM INFORMATION Propert. Address: //p D ?>ak St Owner: Ga'-&CK Date of Inspection: 98 RESIDENTIAL: FLOW CONDITIONS Design fiov, -30 g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: 2 Garbage g,, der (yes or nw:AQ Laundr.• co--ected to system (yes or no, Seasonal use !yes or no! Water meter readings, if available (last two (2) year usage (gpd): Mwn I aJ r rendln (,txreO/1Ct�/Q,/Gi�/t, Sump Pump (yes or no:k Last date of occupancy: � nt COMMERCI,k INDUSTRIAL: 'pe of establishment. De n flow. gallonslda Greas trap present: rues or _ Industn �%aste Holding nk oresent: wes or no+_ 'son-sanit � Haste des rged to the Tale 5 system: ryes or nol_ eater meter eadin , it available Last Pate of o nc. OTHER: ( escribe Last dat of occuoancv GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping TY OF SYSTEM e Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Pri.y Shared system (yes or no) (if yes, attach previous inspection records, if any) __!111 VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: I NSTQeo� r`PPI �r 93' M erri mack "qn crWort�' $ervlce I�itc Sewage odors detected when arriving at the site: (yes or no) X �3 p,ll (revised 04/25/97) Page S of 10 r• FILE# 131 L4 8.4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C J SYSTEM INFORMATION (continued) Property Address: Owner: G—af- Date of Inspection: lL Mp r. 137 BUILDING SEWER: (Locate on site plan) Depth below grade: / Material of construction: ✓cast iron _40 PVC_other (explain) Distance fromovate water supply well or suction lv-� Diameter /' Comments: (condition f�joi s, v ming, evidence of leakage, etc.)If / eo /.JOS G / f2 �t a/ n,W,4 SEPTIC TANK:VS (locate on site plan) Depth below grade:Z� / Material of construction: V Concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No; 004/ Tank Dimensions: !o c-x Q w x 5 N lnyerf ,0 42 �5 Sludge depth 16,"1 Distance from top of sludge to bottom of outlet tee or baffle: 23- Scum thickness- Ort Distance from top of scum to top of outlet tee or baffle:_ n Distance from bottom of scum to bottom of outlet to or battle: How dimensions were determined:��e rV Cr Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, Oepth of liqu d leve! in relaCon to outlet invert, structyral integrity, evidence oakage, etc.) tM e C S a f I rm 1 i Ile ie , e a r jot idi f C- RAP:( REASE TRAP:—&— (I I to on site plan) Depth low grade: Materia f constru n: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions. Scum thickne Distance fro p of scum to top of outlet tee or baffle: Distance fr m om of scum to bottom of outlet tee or baffle: Date of I t pump g: Com nts: (rec,9mmendation for p ping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural intggnty, evidence of lea e, etc.) (revised 04/25/97) Page IS of 20 FILE# 03kG984 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I q o � OiAner: Garb) Ck Date of Inspection:IL Mq r 9 NT,IGHT OR HOLDING TANK: TaAk must be pumped prior to, or at time, of inspection) (Ideate on site plan; <' Depthlow grade: Material of gvonstruction: _con/re —metal _Fiberglass _Polyethylene _other(explain) .kms f. Dimensions: , Capacm: lions Design flov`. goons%day Alarm level. AlarrTi;fit_n working order _ Yes; _ No Date of previous umpmg , Comments: (condition 1s. inlet tee, condition of ala`rrn and float switches, etc.) F 7i ep4{ below Irckotq- Z f' DISTRIBUTION BOXI&S (locate on site pian- Depth of liquid level above outlet invert Comments: note if level and distribution is eq al, evidence of olid car ov r, evidence of leakag into or out f ox, c.) I - t g Lever S i n 2 Clean *01 t' er ' 54-40 - joedc, PUMP CHAMBER:6 (locate on site plan; Pumps in working order: (Yes or No)�5 Alarms in working order (Yes or No!.LLID Comments: l (note condition of pump Ch mber, con ition of umps d appurtenances, etc.) ),tit C i�awlr rjecfM $ 40 Let e s Ir (revised 0{/25/97) haps 7 of 10 ' FILE# 3 4 9 4?A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: qD 1011f St Owner: G•arbl C-k Date of Inspection: ,L MA f cM SOIL ABSORPTION SYSTEM (SAS):, -es (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: A S 114 43 Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: 2 TrencAe S 3 w )(,56 1— leaching fields, number, dimensions: 5 C '{D -PVC_C 44�aC�Ptff,5 overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil,,signs of hydr uh failur „level of ponding, conditio f vegetation, etc.) t a d v f na a -14; n ESSPOOLS: /V (I cate on site plan) Num r and config ation: Depth- p of liqui to inlet invert: Depth of olids I er: Depth of s m yer: Dimensions cesspool: Materials of struction: Indication gro ndwater: flow (c sspool must be pumped as part of inspection) F r Corn"rits: (nate condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.) r IVY: (I to on site an) Materia o construction: Depth_ o olids: Dimensions: Com ts: (note onditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Pay I of 10 I • I FILE# 0 3 16 9?A . I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j SYSTEM INFORMATION (continued) Property Address: 19� l�Q(e S` O%ner: Garr bl Ck•- Date of Inspection: F --� - C SKET OF WAGE'DISPOSALSYSTEM: ( �) e�ude ties to at least two permanent references landmarks or benchmarks I to all wells within 100' (Locate where public water supply mes into house) I i I i S� (6 HHr98r- � 5top s - C Ccu , 1 PL f v O Tahkt�Tt� kwa(I ----- -- --- - __---- ------ A b TI - 3! 13 fd Ti = 144-;3 '' s,45 40 ►Ment_ 110, (revised 0{/25/97) Page 0 of 10 I ~ FILE# 9316 9 FA ' I - I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c SYSTEM INFORMATION (continued) b Property Address: 1 L L Owner: 6a r b i6- Date of Inspection: I / Mqr c Depth to Groundwater 5 Feet Please indicate all the methods used to determine High Groundwater Elevation: VObtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health / Check FEMA Maps V Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) t�o� Iia s cir $' Fau via�o-v7 LjaAer , A0 '5L w1( pL>r" , !1 z> 5 i r, OT t'+O fe D�tJ9 1 h �Qr� ) Y)ear SyST;w► , a. "Ti.00 ;vt o����r�',)ce �ettt�ereh ��►czv+e. -}�t.�e SyS�i'.� irj a✓fc>� �re. d= (ravii1ad 0{/25/97) Page 10 of 10 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: is f 10,l n r) SYSTEM OWNER& ADDRESS SYSTEM LOCATION oo zcu-o (example: left front of house) N -A DATE OF PUMPING: i a. QUANTITY PUMPED 15 o a GALLONS CESSPOOL: NO ✓ YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE 'BAFFLES IN PLAUE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: r plr o i r e e, COMMENTS: , CONTENTS TRANSFERRED TO: -� 1_G,�Jt-FAA r 4 ' 107 Forest St. FILE#0316 9FA Middleton,MA 01949 (508) 774-2772 1 O} ,�,� SEPTIC & DRAIN SERVICE APR 2 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: Gc r�l C. ' PROPERTY ADDRESS: ADDRESS OF OWNER: Saws p— (if different) DATE OF INSPECTION: ► („ p it Q 4$ NAME OF INSPECTOR: 7-v)0vv%iq-S T iQat •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • ' I FILE#(X.310FA 107 Forest St. Middleton,MA 01949 (508) 774-2772 C'&rAVA9K SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Ga,rbl�_k Address of Owner: c Date of Inspection: IG HATICh 191% (If different) Jame' Name of Inspector: lhorn IYS T C11kI4RS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Currier Set IG t-Drain J_hc Mailing Address: r Telephone Number: C97$ 7 7 Y-277Z CERTIFICATION STATEMENT I cenif) 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Cond t onally Passes ',eeds Further Evaluation By the Local Approving Authority Fads Inspector's Signature: �0 Date: JL 14148 )99? The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check ® B, C, or D: AJ SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indicate yes,no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Woe Web: http*www rmgnetstate ma.us/dep 0 Printed on Recycled Paper • FILE# 3 169R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: IgD to/e St Owner: (sp.l`q f K Date of Inspection: BI SYSTEM CONDITIONALLY PASSES !continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if /th approval of the Board of Health): /�/ broken pipets) are replaced oostruaion is removed 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 protea the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: MCesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'v*well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply, well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER A/ (revised 04/25/97) Page 2 o1 10 • FILE# 3 SUBSURFACE SEWAGE DISPOSAL SISTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1,76 We 5L Owner: &ar b;Cis Date of Inspection: D) SYSTEM FAILS: 0 l o us: indicate ether "Yes" or "No' as to each of the following: 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The oas for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corm the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS o- cesspool. Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SA5 or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov,. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes;. Number of times pumped _ _ Any ponion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Anv porton of a cesspool or privy, is within 100 feet of a surface water supply or tributary to a surface water supply. /.ill Any portion of a cesspool or privy is within a Zone I of a public well. ILA Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any port on of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with r-O acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis foo cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: u must indicate either "Y ' or "No" as to each of the following: The following cn ria apply to large systems in addition to the criteria above: The systerti se es a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic heaIt and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply ._ It system is within 200 feet of a tributary to a surface drinking water supply the s tem is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public ater supply well) The owner or operator of any uch system shall bring the system and facility into full compliance with the groundwater treatment program utrements of 314 CMR 5.00 nd 6.00. Please consult the local regional office of the Department for further information. r� (raviaad 0{/25/97) Paga 3 of 10 FILE# P3/G /?-4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J C> �e S Owner: Garble Date of Inspection: tj w--5 3 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N;A_ f _ The facilav or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site .%as inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The faciliry owner tand occupants, if different from owner were provided with information on the proper maintenance of Sub-Surface Disposal Svstem. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.3023)(b)) (revised 04/25/97) Paye 4 of to I,I FILE# 3/694 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q SYSTEM INFORMATION Propert+ \Address: �/� G�Ie St Owner: 6?4rb;V-L Date of Inspection: 1� 98 RESIDENTIAL: FLOW CONDITIONS Design fiov` al4g.p.d2oedroom for S.A.S. Number of bedrooms:_ Number of current residents: 2 Garbage g,- der (yes or nw:-&Q Laundry co--ected to system ryes or no):*5 Seasonal use :yes or no):�i� // / Water meter readings, if available (last two (2) year usage (gpd): TUWYI LJLL e ' ' r(?ac�yn were-UnQV'a zab/�, Sump Pump Ives or no : ko Last date of occupancy: C1XfPf?� COMMERCIAUINDUSTRIAI: �pe of establishmeL De n flow:_ Greasetrap present Industrial ��aste HoPresent: ryes or no ton-Nonwaste he Title i system: (ves or no) 1�`ater meter ead�nlast�a;e of o OTHER: i escribe Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes Or no)_ If yes, volume pumped: gallons Reason for pumping TY E OF SYSTEM . e Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) !1�j _ VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: j IvSTa.t1�` _ r ��, I �/�_ M errs wrack ►»c-pi-I,� 5erv�c�me Sewage odors detected when arriving at the site: (yes or no)�( GAo' 3 A.K (revised 04/25/97) Page 5 of 10 ' FILE# g,VT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I-/Q O e S Owner: Gat- I r_k _ Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grader / Material of construction: /cast iron _40 PVC_other (explain) Distance fromnvate water supply well or suction II , Diameter �' � Comments: (condition fjjoi s, v nting, evoence of leakage, etc.) L / 7?) vri /I oN, iflaYi SEPTIC TANKS (locate on site plan) It Depth below grade:2� Material of construction: /concrete _metal _Fiberglass _Polyethylene _other(explam) If tank is metal, Inst age _ Is age confirmed by Certificate of Compliance _(Yes/No, Dimensions JC) j-X 5 W x 5 H lhyerf 2 it X50©�Q/ -ran k Sludge depth-�[a 11.1 ti Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness 2" U Distance from top of scum to top of outlet tee or baffle:�� �r Distance from bonom of scum to bottom of outlet to or battle: _ How dimensions were determined: a rvler- Comments: (recommendation for pumping, condition of inlet and outlet tees or ba es, epth of liqu d level in relation to outlet invert, structYral integrity, evidence of leakage, etc.) u y" e L C S one- 1") rm ("1 i �l e f / e e e Vfrop AP: site plan) w grade: construct' n: _concrete _metal _Fiberglass _Polyethylene _other(explain) s. ne o p of scum to top of outlet tee or baffle: Distance fr m om ofscum to bottom of outlet tee or baffle: Date of I t pump g: Com nts: tf_c mmendation for p ping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural irity, evidence of lea e, etc.) J ,/ (reviped 04/25/97) Page 4 of 20 FILE# 03/0?-4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C G� J SYSTEM INFORMATION (continued) Properh Address: I-1 o �• �j ONner: Garb) C}- Date of Inspection:I �r Q�y "-TIGHT OR HOLDING TANK: 'T must be pumped prior to, or at time, of inspection) (locate on site plan; Depth below grade: Material of,.Eonstructton: _concrete _metal _Fiberglass _Polyethylene _other(explain) ^:x Y Dimensions: ^, Capacity lions Design ;low: gonvda� Alarm level. Alar nf n working order_ Yes; _ No Date of previous umptng �-t. Comments: (condition ofr inlet tee, condition of alaktrry and float switches, etc.) N. �n 7i e�h below gr�-ade; ►i'' DISTRIBUTION' BOX: &S (locate on site pian: t� Depth of liquid level above outlet invert. Comments: note if ievel and distribution is eq al, evidence of olid car ,ov r, evidence of leakag into or out f ox, c.) I - ca�c 1,5 g Leve_ S i h e e Q r C ea + r TIN,ere'_5be G Ajo h wo 01 Sc-Leo S a PUMP CHAMBER:5 (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No:�NQ Comments: I ` (note condition of pump ch tuber, condition of pumps d appurtenances, etc.) V� C�w 6r Seew S IU e- 'e m Ct S Vent n e (revised 04/25/97) Page 7 of 10 • FILE# -? 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) T Property Address: NO bole st Owner: GcArk ck. Date of Inspection: 'L MA r CM SOIL ABSORPTION SYSTEM (SAS4es (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: 2 Trien -,es 3 Lo X(-Q 4 ,, leaching fields, number, dimensions: SG f{D I V C�agck PIFe s overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil,,signs of hydr ulic failur ,level of ponding, conditio f vegetation, etc.) t n Q - t> ► n a a I a ESSPOOLS: LCL (I tate on site plan) Num rand contig anon: Depth- p of liqui to inlet invert: Depth of olids I er: Depth of s m ver: Dimensions 'cesspool: Materials of struction: Indication gro ndwater: flow ( sspool must be pumped as part of inspection) Comments: (n?te condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.) t` IVY: (I to on site Ian) .Materia o construction: Dimensions: Depth o olids: Comm ts: (note?nditi•n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) .t r trevisad 04/25/97) Page t of to FILE# 0 3 16 9 FA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19t' 1�C��' St ONner: Go vl C�- Date of Inspection: r SKE- OF WAGE DISPOSAL STEM: ( li c4ude ties to at least two permanent references landmarks or benchmarks I ,te all wells within 100' (locate where public water supply mes into house) I la l r SQ ( Or Sl�� W r,3 2 Ate e" -rrre,�"�-k e - -_ - - -- --- D-BoX 5 C / Nouse � � r i = t v Q sep+lc 4 `fanl�(T� ck�lt 7=: JII-!3 (revised 0{/25/97) Page 9 of 10 1 FILE# 93/6 9 6A SUBSURFACE SEWAGE DISPUSAI SYSTEM INSPECTION FORM PART C ` (( SYSTEM INFORMATION (continued) Property Address: f q0 L Owner: 6a r b'i6, Date of Inspection: I / Mja r. 9 Depth to Groundwater 5 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) VDetermine it from local conditions Check with local Board of health / Check FEMA Maps V Check pumping records Check local excavators, installers Use USGS Data Describe in your own words ho,y you established the High Groundwater Elevation. Must be completed) t`I oma . �a S ar S' ��►� -►�, j 1 �sertetiL 15 atr1 n4> si�►� m , er(f t,�S ee� 1'EDCe D�V9 lh (-1Qfc� ) Y)ea.r r-A Via 3 4. 510 pt. -v a ��l' rt 4e �e�1,0erQ11 sy416AA rs al r,�l,ere dv9 e. �v tc, (ravimad 04/25/97) Page 10 of 10 I Address Title of File Page of Date File Open: 1 Date file closed: Doc Document/Action Title Date of __ action 8tefet to other PurP.ose of DocuMent/Action and nates IWum. Document/ document/ -- Action De artment i i Board of Appeals — Board of Heal h Planni%n�g 6o:ard ; Conservation Commission — Building Departm, En;t �-- RECEIVED Commonwealth of Massachusetts City/Town of �G� i��� OCT 9 20 1 TOWN of NORTH�tnovEt System Pumping Record HEALTH DEPARTMENT Facility Information: System Location: Address A7-p�,,eA Clic f S City/ wn State Zip Code System Owner: (3 Name: Adress (if different from location of pump) City/Town State Zip Code Cob R -- 424 -7 Telephone Number Pumping Record Date of Pumping l( Quantity Pumped S gallons Type of System ?C Tank Grease Trap Other (what) System Pumped by: (_ v r t Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01843 Location where contents we di 'Posed: _^ Signature of Hauler Date / J. W. WATSON JR., INC. 53 Dascomb Road Andover, MA 01810 i i J. W. WATSON JR. INC. 53 DASCOMB ROAD ANDOVER, MA. 01810 TO PAM CURRAN : THE SEPTIC SYSTEM ON 190 DALE ST. NO. ANDOVER MASS. HAS BEEN REPAIRED TO THE SATISFACTION OF THE BOARD OF HEALTH IN THE TOWN OF THE NO. ANDOVER. SIGNED: INSPECTOR _ -