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Home My WebLink AboutMiscellaneous - 192 STONECLEAVE ROAD 4/30/2018 (2) 192 STONECLEAVE ROAD Road - 210l104,11-0130-0000.0 l 11 r 192 STONECLEAVE ROAD Road - 210/104.B-0130-0000.0 i I Q V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 page. 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. Important:When filling out forms A. General Information RECEIVED on the computer, use only the tab 1. Inspector: APR O 9 2013 key to move your cursor-do not James Wright use the return Name of Inspector TOWN UF NORTH ANDOVER key. Aspen Environmental Services LLC HEALTH'DEPARTMENT Company Name 270 Lawrence Street Company Address Methuen MA 01844 Cityrrown State Zip Code 978-681-5023 2035 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 ❑ Needs Further Evaluation by the Local Approving Authority rjlnsign Dateem 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. l5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner owner's Name information is required for every North Andover MA 01845 3/12/13 page. City[Town 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 nditionally 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): tsins•11/10 Title 5 Official Inspection Forth;Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts JD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): distribution box is leveled or replaced Peyl-"11 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 HeOW determines in accordance with 310 CMR 15.303(1)(b)that the system is not fctioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is wit in 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 'e 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 page. Cityrrown 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 aseptic tank and.SAS and the S S is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS a the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS an a 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 wat analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent a d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided th no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D System Failure Criteria Applicable to All Systems. You must indicate"Yes"or"No"to each of-the following.for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or ogged SAS or cesspool ClDischarge or ponding of effluent to the surface of the ground or surface waters Slue to an overloaded or clogged SAS or cesspool ❑ .L—M'/ Static liquid level in the distribution box above outlet invert due to an overloaded or,clogged SAS or cesspool ❑ quid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . r 192 Stonecleave Road Property Address Susan Greeley Owner owner's Name information is required for every North Andover MA 01845 3/12/13 page. City/Town 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: ElL( 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. ❑ ny portion of a cesspool or privy is within a Zone 1 of a public well. ❑ "ny 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 ata DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10'000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is in 400 feet of a surface drinking water supply ❑ ❑ 16' m is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ em is located in a nitrogen sensitive area(Interim Wellhead Protection WPA)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. 15ins•11/10 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 Y 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 page. 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 ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 facilityor dwelling n 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: Lam' 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11/10 Title 5 Official Inspection Form:Subsiaface Sewage Disposal System•Page 6 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA . 01845 .3/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes rd' No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes QNo Laundry system inspected? ❑ Yes 1:1- ao Seasonal use? ❑ Yes DNo Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? Yes ❑ No Last date of occupancy: e Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pre nt? ❑ Yes ❑ No Non-sanitary waste dischar ed to the Title 5 system? ❑ Yes ❑ No Water meter readings,.if available: t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts • QuVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: ��r Was system pumped as part of the inspection? ❑ Yes P-<o If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner).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•11110 Title 5 Official inspection Forth:Subsurface Sewage Disposal system•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner owner's Name information is required for every North Andover MA 01845 3/12/13 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes to Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron U4'0"'PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): �� " ,1��ci,� •- �Lam, `"�7�� =/=L` Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ncrete ❑ metal El fiberglass [I polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of.Compliance?(attach a copy of certificate) /p❑ Yes ❑ No Dimensions: 2 {7` /9 Sludge depth: t5ins-11/10 TAIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner owner's Name information is required for every North Andover MA 01845 3/12/13 page. Cityrrown 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? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickne Distanc rom top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Fort: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 Wt 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 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 le , etc.): 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: ga Design Flow: gallons per day Alarm present: El Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is North Andover MA 01845 3/12/13 required for 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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evi ence of leakage into or out of box etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump cha r, condition of pumps and appurtenances, etc.): j 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 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: al- leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool Elnumber: ❑ 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.): 10 ^ 1 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 constru ion Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 iL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner owner's Name information is required for every North Andover MA 01845 3/12/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note con it 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments lug 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is required for every North Andover MA 01845 3/12/13 page. CitylTown 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: Ld- _"d-sketch in the area below drawing attached separately t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Ddvewsy } G" �aarityiloon� . : - HAD A • Porch TQk B box. A to 1 mZZ•T,. A to 1 !$Ojt" A to I)L%x 39' - Bto2=21'1 '' Bto&Bu=T7" r .. j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is North Andover required for every MA 01845 3/12/43 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Z'Slope ❑ Surf water Check cellar ❑ Shallow wells Estimated depth to high ground water: ' �,f 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: l / 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: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Fonn: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 192 Stonecleave Road Property Address Susan Greeley Owner Owner's Name information is North Andover required for every MA 01845 3/12/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked ef"Ins ection Summary D (System Failure Criteria Applicable to All Systems)completed Sy m 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 5 Official Inspection Form:Subsurface Sewage Disposal poral System•Page 17 of 17 5�{-%ED'�` . • ■ I PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 4/16/2013 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Repair of Pipe and D-Box By: Todd Bateson At: 192 Stonedeave Road Map 104B Lot 0130 North Andover, MA 01845 T s'uance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. n. ) All, Michele Grant Public Health Agent � �.. SCP I 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com � SC.�TLED l6aG �p�kATED AY��4 North Andover Health Department fommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 192 Stonecleave Road. MAP: 104B LOT: 0130 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS Pipe and D-Box TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 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 Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base DIDN'T SEE ® H-20 D-Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) Comments: Commonwealth of Massachusetts City/Town of System Pumping-Record .VForm 4 F NORTH ANDdVER DEP has provided this form for use-,by local Boards of Health. OthCeMusing.this q W949, but the information-must be substantially the same as that provided here. 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 hous Le . Rig rearof , 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 Zip Code 2: System Owner. Name' Address(if different from location) . Citylrown - .. State ` ` P J5 Telephone Number 7 .B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons y 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ Na ' 5. Condition of System: 6.- System Pumped By.- Nell. y:Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo ere contents-were disposed: AHau1W Lowell Waste Water G) l&SignDate t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town ofRECERED ED System Pumping Record Form 4 t IAY C 5 2014 � � Eo�;t� DEP has provided this form for us&.by local Boards of Health. Other Wffiytrb�elused,b i information must be substantially the same as that provided here. Bewith 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(@D/D/Rig ��ofhoe, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/ f building, Under deck Address C� C�P�� V-� city/Town State Trp Code 2. System Owner. Name Address(f different from location) cityrrown ' Sta Pp Telephone Number B. Pumping Record p B �C A Y 1. Date of Pumping gate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition f System: 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. LocatigAwhere contents were disposed: G.L S'. Lowell Waste Water Sig Haule Date t5fbrm4.doc-06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts REcEIVE0 _ City/Town of 1-J"R 2 2 2013 System Pumping Record TOWN OF NORTHANOO y Form 4 HEALTH DEPART�E�R DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of housLe Righ ar o=house�Left/right side of house, Left/ Right side of building, Left/Right front of bui Ing, Left/ rig rear of building, Under deck Address J Citylrown State Zip Code 2. System Owner. Name Address(d different from location) City/Town State Zi Code Telephone Number B. Pumping Record 1. Date of Pumping 2. QuantiQuantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No " 5. Condition of System_: v'\ -Acft&�6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: GLt_S.Q Lowell Waste Water cS—C3 Sig4tufe 4 Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 13,5 VA Z T / 7 /O o PtAl ot— Alz- i t I t L h i • t I • �gc�°� Map-Block-Lot Commonwealth of Massachusetts 104.B0130 BOARD OF HEALTH ----------------------- North Andover CERTIF TE OF COM L NCE IS IS TO CERTIF ,That the ndividual Sewage D' posal S tem (Repair) by T dd Bateson. --------------------------------- Installer at N 192 STONECLE OAD has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2013-060 Dated-__March 25,2013_ ----------------------- - - - - ..... ----------------------------------------------------------------- Printed On:Mar-25-2013 BOARD OF HEALTH • ;� °fes' . Commonwealth of Massachusetts Map-Block-Lot } r• 104.130130 BOARD OF HEALTH -------------- P-ermit No North Andover BHP-2013-0607 ------------ -- -- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson - - - - - ----------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 192 STONECLEAVE ROAD ! CO-------------------------------------------Y - iftu�� as shown on the application for Disposal Works Construction Permit No. BHP-2013-060 Dated March 25,2013 ---------------------- ----------------------------- ----------------------------------------------------------------- Issued On: Mar-25-2013 BOARD OF HEALTH • N°RTM Application for Septic Disposal System3 — s— 3: ��'+ •�•°°� TODAY'S DATE Y :Construction Permit — TOWN OF �� - , MA 01845 $250.00—Full Repair ORTH ANDOVER �'�S'"•t $125.00-Component SAtHUs 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 to.move your R"I'lepair or replace an existing system component—What? cursor-do not use the return A. Facility Information key. rar Address or Lot# City/Town d- q, 2.- *TYPE OF SEPTIC SYSTEM*: MAR Z 5 2013 ❑ Pump ravity(choose one) TOWN OF NORTH ANDOVER ***If pump system,attach copy of electrical permit to application*** HEALTH DEPARTMENT ®'Co"nventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-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 Susdw Name Address(if different from above) City/Town State Zip Code q7 ' Telephone Number 3. Installer Information Name Name of CompanPAUZON ENTERPRISES,INC. 111 ARGIUA ROAD AMD(AfER MA 01 8i o Address— "yee-_ Olt+- dlgl/v City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 G�" :T ;+a, Application..for Septic Disposal :Systema ,� TODAY'S DATE p construction Permit - TOWN OF -ORTH ANDOVER, MA 01845 $.250.00-Full Repair -Component PAGE 2OF2 A, Facility.Information continued.... 5. Type,of Building: esidential Dwelling or❑commercial B. Agreement 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 issue by thisBoardof Health. Name Date Applicatio pproved By: (Boar f Health Representative) Name Date Application Disapproveld for the foll wing reasons: For Office Use Only: 1 Fee Attached. Yes No 2. ProjectManiger Obligation Form Attached. Yes No A: PumUS sv tem? Ifso)Attach co2y ofElectrical Permit`. Yes No 4. Foundation As Built.?(new constructionronl}i); Yes_ No (Same scale as approved plan) — 5. F1oorPlans?(new construction only).. No Application for,Djsposal Sy tpth:Odnstractioo Permit,',Page 2 of 2 SEPTIC SYSTEM.INSTALLER PROJECT MANAGEMENT pBLIGATIONS aller fcsr the construction for the septic system-fot.the property at As the North Andover-licensed inst For plans by (Address of septic system) (En Relative to the.application of O`er `� And dated (installer's name) nguia e). Dated .:3 13 With revisions dated kioday s ate (bast re 'sed date) I understand the following obligations fur management of this project: 1. As the installer,I am.obligated to obtain all permits and Board of Health approved plans pdoT to ,performing any work on a site: I must have the approved tilans and the permit:on site when anv work is beim done. 2. As the installer,.I miist call-for any and all:inspections: 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. As.the installer,I a=_-required to.have the necessary work-completed prioY to the.applicable inspections as indicated below I understand that reeauestinr, an inspection,without completion:of the items in.accordance witli Title 5 and the Boafd of Health Regulations may result:inta-W 001 fine-beffi levied aMst:me..and/or .inv company: a,. Bo'tfom of Bed Generally,this-is the first.(1°`);inspection unless.there is a retaining wall,which shoulcl•be done first. The`installer must west the inspection but does not have to be present b. Final-Construct ori.Inspeetion—Engineer miist:firs :do their inspection for elevations;ties, etc. As-built of verbal OK(or a-mail xo:liealthdeDtOtownofnorthandover.com):from the engineer must be submitted-to.the.Board of Health,after`crhich installer.cails 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*ork and,alarm.to function.. c. -Final -Installer must request inspection when. grading Js complete._..Installer does not have to be on=site. 4. As-the installer,'I understand that only 1.=y perform the work(other than:simple excavation)and I am required to complete the-installation of the system ed in the attached application for.installation: '.I further . .understand:that work done�bZ others ui liceh sed to,installseptic systems in North Andover can constitute reasons for denial of the system andlo4revgcation-or suspensioti of.my lieense.to operate in the Town of North Andover sig"ficant fines to alljiersoiis-involvei are also possible 5.. As the.installer,:T understand that:I must be onsite during the,perf6iniance of the following construction. steps: a: Detemllnation tbat.the proper efemdon of the exc v2don has been reached b. Inspection of thebsand and stone to be used. c. Finallnspection by Board ofHealth staffor consultant. d. Installation.,of t u*D Box;pipes,stone, vent,pump chamber,ret oZIg wall and other components. 6. As the installer,I understand that I=solely respQnsible for the installation.of the.system as per the approved Iilans No instructions by thehomeowner,goneral.contractor_-or any.other persons shall-absolve me!Rf this obligation. Undersigned Licensed Septic.Installer: (Today's Date)` (Mane,—grintj , OW f sAa Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT LL n WELL LOCATION GEOGRAPHIC DESCRIPTION P' Address n n NO E W of �'T_ (reef) /circle! City/Town - .� fry rl rat. e Well owner I 1 (road) Add re s _. ? "AD S E of klrcle/' Board of Health permit obtained: yes no❑ intersect. w/ /Foadl _ WELL USE WELL DATA f Domestic P01ublic❑ Industrial ❑ Total well depth( �}_it. s Monitoring❑ OtherDeptthh to ro`bedft. I a�V ter-bearing rock/un nsolidaled material: Method drilledl r t Date drilled – Description – -C!� —SOP CASINGWater-bearing zones: y 1) From ..To Type e P Length�_ft. Di.(J.D.)�in. 2) From To 3) From To Length into bedrock �� 1t. Gravel pack well: dia. Protective well seal. Screen: dia.. Grout Other Slot + length from_to STATIC WATER LEVEL(all wells) Static water level below land surface ft. Date WELL TEST(production wells) Drawdown after pumping�hr. min.at gpm How measured ecovery�ft. afte��hr. min. t�j0 LOG of FORMATIONS COMMENTS i Materials From To Driller Firm`f, r, Address- City/Tow, ddress-City/Tow / r "Supervis' riller Reg.tl rE"or rvisln $ ' re //drl(ler -oo' BOA40 OF HEALTH CQR1! I BOARD OF HEALTH Town of North Andover h1ass . ' ........-• Dates' 19 ' ermit t APPLICATION FOR WELL & I'Uh1P ' ' NORTH ANDOVER/ BO)NRD ti n is 1ppl`ication . is hereby made for permit to, drill a we 1 _ ,,nade to install. (_) a pump system. NOV 2 . Lo9t5 ocaCion: Address S O �� Address l� fel -Jwner • / cl . 14ell Contractor l s AddressAga Address_�!� `T �J® T e L �T .aump Contractor vy� -j db `,JELL CONTRACTOR (To be completed at Limc of }wily test: ) 'Type of Well raoir Well used for 7/� Diameter of Well �( Size of C'asi.ng !� To De th casing into Bed Rock oe Depth � Bed Rock 1 S p ,Was Seal Tested? Yes ( No ( ) Date. of Testing Depth 7� Well Ended in What_ Material 6R4vI e +Dr th Co Water Gals . Per t1in . for 4 hours Drawdown !� O feet after pumping _1io��rs a Date of Completion gn e �JeIZ tractor ..PUMP INSTALLER (To be'' f-i-llcd in- before insta].l.ation ) !/� Pump _ —_-Pu►np .type Used ,Sc;c/JiY►P�ft� Size & Name p YJ _��L�-•---------- -- 1 Size of Tank �G' W.9Z �/ X Water Pump Delivers _GPM Pipe Material Used in Well : Cast Iron ( _) C;a ] v.lnized (_) Plastic (�K Wc11 Pit (_) or Pitless Adapter J sleeve used to protect pipe? Yes (_) NO(_� 1'Y1�e or Name Well Sea1Ly�� Was a Date 7 9J �4�r�t7�iY��4�'c �'�i'r�4��C�`��'r��r�'r�'c�4tC�4s4�4�'tai'ri'r�C�4i4�'c�4�4�4�4�'��4��t�4�'rti'rt4�'��'c ` ,',;::•,:;c,c r ,,rt:,:,:::.• : ;::: , : , irshdr�r. p *e Water analysi*s'. r'epor-t. 'submitted to Board of 11eal'th Da _e .release given W owner of record & 111cig .. Insp Health Inspector t i I t k � i 00 Vt t ly.t C� JJJ - 2 y TOWN OF NOF ANDOVER/ BOARD OF n4 140' 1 NOS/ 2 9 1 t,` l LCT IT _ . - a mf G A(h- v URVSPLAN A REG1 �$TQREa L. ANO SURVIL f RANK C LL N S. Yotk �Sl /6,NDOV�A S^Cot.�T - NOIA'Tw ANoov[ct , MASS . � 1iLAi8Y cam'riRYT4ATYHe5uliL) lC� ;HOWN "" "- dAITI{1'> piA1V i'ilOCr.TLO C+VrWt GotouNo As DATL : ;^.i,_� 7;^ SmawNAN0TKATITC*NF0ArmS Y T a Z0 Ni Nr, PLAN P[ F !a!'tVCL •. LAwsGFTHE CITY/TOWN OF NJ in, 10T.�.L7r 10 A PLAN SY — `• W"CN CONST0T o 4 !A DATi.O , AND RtCOROIL DIN 'S �GtaED' acs cty or blas . AG�. N 4. •�-�'�`4' 0o_K NA P NOTA: � �� 7 � �.� G{-�'�• •�'': t PMIOP�R1YLINL ANo S'rR9gTLINA, dfiFSL-fl s►rowNoN-vmia Pi AN 'AAL 6PLCI91'tAkY ;OPtT-WL �Tr.e�• Plw�rr--i —, — Kw •r r.Rl I%Le 0 c A. t i a t►w,ff.•.74 Niel II/ t NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTSTOWN ....... of .........NORTH ANDOVER ................................................................... This is to Certify that ....Skillings--&---Sons NAME ..........2-6.9...Prar-tox...Eill...RoaLd Hall-i-s.r .hi-H-.-Q3n49........................................... ADDRESS IS HEREBY GRANTED A LICENSE For ...................•----- Well Permit - 192 Stonecleave Road, No. Andover ............. ......................................................................... ............................................................................................................................................................................. ............................................................................................................................................................................ ..........................................................................................................................................*-------------*-----------------* This license is granted in conformity with the Statutes and ordinances relating thereto, and expires......De-c.ezber--- .............unless sooner pspended or revoked. lqjs .................. • ---- ------------------ - --- --------- ----- Re.C'.e M be.r... .......................19...95 T-7;--- ----------- ............ ........z... ... ...... .... ................. ......................... FORM 433 HOBBS&WARREN T" ... ..... . . . .......... a ,r o Po WOOGAa'o IL b 30'+ 7, 71 "'`- Dom'E //iia C- --� 30' t 7-AO/ FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ************��*//***Appli/c//ant fills out this section***************** APPLICANT: C7/�� AWv .,7 Phone 0 LOCATION: Assessor' s Map Number Parcel Subdivision Lot(s) Street l 5 Z 5to c- ee, ye St. Number le-7 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Ji v Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments TC-` --7395--S d Public Werks - sewer/water connections _ - driveway permit Fire Department Received by Building Inspector Daze NORTH ANDOVER ,BOARD OF HEALTH SUBSURFACE DISPOSAL SYSTEM CHECK LIST APPROVED PROVIDED DISAPPROVED 7 eneral Information .leg. 2.5 ail 'The submitted plan must show as a minimum: Ca) the lot to be served (area,dimensions, lot #, abutters) leo (b cation and dimensions of system (including reserve area) c.1110 ) esign calculations calculations showing required leaching area existing and proposed contours location and log of deep observation holes-distance to ties vcation and results of percolation tests-distance to ties location of. any wet areas within 100' of the sewage disposal system or disclaimer —surface and subsurface drains within 1001 of sewage disposal system or disclaimer location of any drainage easements within 1001 of sewage disposal system or disclaimer 4k.) lalo� sources of water supply within 2001 of sewage disposal system or disclaimer (1) location of any proposed well to serve the lot(1001 from leaching facility) ocation of water lines on property (101 from leaching facilities) maximum ground water elevation in area of sewage disposal system o ion of benchmark p plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans veways bage disposers a profile of the system (elevations of basement, plumbers pipe septic tank, ,distribution box inlets and outlets, distribution field piping and any other elevations) PVC is to be used in construction Septic Tanks Reg. 6.1 a apacities - 150% of, flow Reg. 6.7 Nater table Reg. 6.$ c Tees Reg. 6.9 th of tees Reg. 6.1 ccess leg. 6.1 Pumping Cleanout leg 3.7 101 from cellar wall or inground swimming pool {#� 251 from subsurface drains < s leg: 9.1 a Approval leg. 9.6 (b) Stand-by power NO.R.TH nNDOViR BO_kRD OF HEPITH !iI S A1�Lr'T I U Cr=iK .LIST APPROVED • DIStiPPROVr, EXCAVATION OK ��^ Date: Date: 1. As Built Submitted Check: Lot location, dimensions. of system, location in regard to percolation tests, depth of system, water table 2. Distance to YTetland Areas, Drains, Street & House, Drainage Easement and Wells. 3. Water ine Location 4. No PVC P ne 5. Septic Tank - s, Cement--P' e to Tank Joints on both side of Tank. b. Distribution Box - No cracks in box cover, all line 6w ec_ually from box. 7. Leach Fields Dime nons, Stone D ths, Capped�e , lean double-t; she tone $. 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 10. Final Grading k'�barricading of sub-surface system' f ndover Subsurface disposal system check list-Page 2 Fai stribu ion Boxes Reg.102 a) Slope greater than 0.08 Reg.10:4 Leaching Pits Leaching pits are preferred where the installation is possible Reg.11.2 (a) Calculations of-leaching area (minimum 500 S.F.) 11. b 11 Re . Spacing g ( ) � g Reg.11.10 (c) Surface drainage 2% Reg.11.11 (d) Cover material eachin Fields Reg-15-1 reater than 20 minutes/inch Reg.7 5.1 rea (minimum 900 S.F.) Reg.15.4 onstruction of field Reg.�5 8 rface drainage 2% leg. . r 01 from cellar wall or inground swimming pool rwnhi Slope a Slope y/x = (to be shmm) (b) y/x X 150 = (to be shown)