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HomeMy WebLinkAboutMiscellaneous - 20 BRIDGES LANE 4/30/2018 (2) 20 BRIDGES LANE -- 210/104.D-0071-0000.0 J � i Y. IV's RA-4. �.,% ss • 4� /4!Y_�i_�_S COMMA OC /Soo Gal sjoo,-/c- *%L vie t f � i r sx t I • S�q LED,1�6 • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 5/7/13 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: D-Box Repair By: John J. Soucy At: 20 Bridges Lane Map 104 D Lot 0071 North Andover, MA 01845 The Issuanc his certificate all not be construed as a guarantee that the system will function satisfactorily. Sia an "awyer Public Health Agent4 �" /— � ILE �.. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com '1 SST!'to j6a6. North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 20 Bridges Lane MAP: 104D LOT: 0071 INSTALLER: John Soucy DESIGNER: PLAN DATE: IJ BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box TANK INSPECTION: J �� 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 ❑ 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: Gram, MicMle From: Jennifer Boutin [SoucySewer@comcast.net] Sent: Monday, April 29, 2013 2:48 PM To: Grant, Michele Subject: 20 Bridges Lane Attachments: 20 bridges Lane Pic.jpg; 20 bridges Lane Pic2.jpg; 20 bridges Lane Pic3.jpg Michelle please see the attached 3 pics for 20 Bridges Lane, North Andover. The box is flow checked, pipes mortared, and there was 6 plus inches of stone under the box per John. Should you have any questions per my email please call me at the office. Thank you Michelle and have a great evening. Thank You, Jennifer Boutin Office Manager Soucy's Sewer Co. Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:http://www.sec.state.ma.us/pre/preidx.htm. 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Commonwealth of Massachusetts Map-Block-Lot ^,- ; • 104.D0071 BOARD OF HEALTH Permit No North Andover -BHP-2013-0625---------------- ------ FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted S- ucy's Sewer Service - -------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. atNo --20-----BRIDGELANE---------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2013-062 Dated --Apr-i-1-23-,-20-13 ---- --------------------------------------------- Issued On:Apr-23-2013 BOARD OF HEALTH ' - t �• ...Q.T`. Application for Septic Disposal System L 1 ' TO Y' DAT ° VConstruction Permit — TOWN OF ORTH ANDOVER MA 01845 $ 250.00—Full Repair -y y oigo r y �YSSiCNUs�t4g $125.00 -Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ pair or replace an existing on-site sewage disposal system*1( `( A only the tab key to move your Repair or replace an existing system component—What? cursor-do not �� � � (abr/� � use the return key. A. Facility Information •-fes A dress or Lot IF 6 City/Town 2,*TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) APR 2 3 2013 ***If pump system, attach copy of electrical permit to application*** TOWN OF NORTH ❑ Conventional System (pipe and stone system) HEALTH pEpgRTM VER ❑ 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 Name 9 Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information I �} C C C Name Name of Company Addr ss � n —z j city/TownStat Zip Code Tel one Nu �(Cell hone#if possible please) 4. Designer Irif rmation NarxName of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 °E N°;r;gti Application for Septic Disposal System �-S ATE ' . = pConstruction Permit - TOWN OF TODA •e . ,? ORTH ANDOVER, MA 01845 $250.00-Full Repair $125.00 -Component, / / PAGE 2 OF 2 A. Facility Information ontinued.... 5. Type of BOW=p4sidential Dwelling or❑Commercial B. Agreement The undersi ed a rees to ensure the construction and maintenance of the afore-described on-site s age di posal system in accordance with the provisions of Title 5 of the Enviro ental C de,as well as the Local Subsurface Disposal Regulati s for a Town of No Andover, nd not to place the system in operation until a Certi� a of Co pliance has be n issued b this Board of alth. C7- me Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? If so,Attach copy of Electrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? new construction only):Y): Yes No Application for Disposal System Construction Permit•Page 2 of 2 Street&Trench Opening Permit.pdf http://www.townofnorthandover.com/Pages/FV1-00024FEC/Street&... r Town of North Andover RECEIVED Pursuant to Policy &Town Bylaw Chapter 161-3 Street Excavation permit (as amended) APR 2 3 2013 With PERFORMANCE BOND AGREEMENT AND The Commonwealth of Massachusetts TOWN OF N RTH ANDOVER HEALTH MEPARTMENT Jackie's Law— Trench Permit Pursuant to G.L. c. 82A§1 and 520 CMR 14.00 et seq. (as amended) PERMIT APPLICATION — &/or Trench Permit Permit Number: Applicant: Dig Safe Number: �0�3 Y0 ��� ' Date Issued: SITE EMERGENCY CONTACT: EMERGENCY NUMBER: SECTION 1 -SITE INFORMATIO N—PRINTOR TYPE iNBLUE ORBLACK INK 1.1 Property Address: 1.3 Description,location and purpose of proposed L1TeS l Cin M4 street opening and trench: use back of page if needed n fm&oee 6ox 1.2 Map/Parcel Dumber: _a� j essvfe l Pawl 1% oe, Builder's of No: Block: boo)� 1.4 Antici ated Date to Begin O eratio s P 9 P ( (� 00-71 Begin: T' p' 1292 End: r f o?4J3 GIS Property ID: 1.5 Anticipated Date to Conclude Operations Provided by the Town SECTION 2 -PROPERTY OWNERSHIP AND PERMIT HOLDER INFORMATION-PRINT OR TYPE IN BLUE OR BLACK INK 2.1 Owner of Record: joyy) 13i cu)c)i ao iac) n . hamfe_e, Mo a�8u Printed Name & Address b03- 36M-q33 9. Signature Telephone 2.2 Excavator Permit Holder Information: h L� 9 o LA-� � � 0H 0367g Printed e & Ad 8339 Sig to Telephone 1 Emergency Contact Number 2. E aviator Permit Holder Information-continued 1 1 of 5 3/14/2013 1:04 PM Street&Trench Opening Permit.pdf http://www.townoftiorthandover.com/Pages/FVI Competent Person as defined by 520CMR 7.02 a Printed Name: Massachusetts Hoisting License#: W3 9a License Grade : License Expiration Date: 2.3 Name and Contact Information of Insurer: 6a)::s Zn s ra n ce ii lrx> c I a a LhP_4z a /4 Company Name Address Telephone )C' Insurance Certificate#: C i(� L Policy Expiration Date: J Whereas pursuant to the provisions of Chapter 161 Section 161-3 of the North Andover Town Bylaws, the grantee agrees to provide a plan and a bond in the sura of $10,000,00 bound unto the Town of North Andover and an additional refundable amount of $ to assure proper performance and completion as defined in the general specifications and conditions below and as attached. By signing this form, the applicantlexcavator and owner, acknowledge and certify that they are familiar with, or, before commencement of the work, will become familiar with, all laws and regulations applicable to work proposed, including OSHA regulations, G.L. C. 82a, 520 CMR 7.00 et seq., and any applicable municipal ordinances, by-laws and regulations and they covenant and agree that all work done under the permit issued for such work will comply therewith in all respects and with the conditions set forth below. The undersigned owner authorizes the applicant/excavator to apply for the permit and the excavator to undertake such work on the property of the owner, and also, for the duration of construction, authorizes persons duly appointed by the municipality to enter upon the property to monitor and inspect the work for conformity with the conditions attached hereto and the laws and regulations governing such work. The undersigned applicant/excavator and owner agree jointly and severally to reimburse the municipality for any and all costs and expenses incurred by the municipality in connection with this permit and the work conducted thereunder, including but not limited to enforcing the requirements of state law and conditions of this permit, inspections made to assure compliance therewith, and measures taken by the municipality to protect the public where the applicant owner or excavator has failed to comply therewith including police details and other remedial measures deemed necessary by the municipality. The undersigned applicant/excavator and owner agree jointly and severally to defend, indemnify, and hold harmless the municipality and all of its agents and employees from any and all liability, causes or action, costs, and expenses resulting from or arising out of any injury, death, loss, or damage to any person or property Burin a work conducted under this permit. In 'tne s whereof asigned below have here unto executed this agre a t. N L4 APP ANT SIGNATOR ate �� XCAVATOR SIGN E Date OWNER'S SIGNATURE(IF DIFFERENT) D to For 'yfTown use— of write in this section PERMITAPPROVED BY PERMITTING AUTHO ivision o :W0Csf ublicDate 2 of 3/14/2013 1:04 PM 4 T Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not John J. Soucy use the return Name of Inspector key. Soucy's Sewer Service, Inc. L Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: RECEIVED Passes Conditional) Passes Falls ® ❑ Y ❑ ❑ eeds F rther Ev tion by the Local Approving Authority MAY 0 0 2013 TOWN OF NORTH ANDOVER HEAL 11 DEPARTMENT Ins or's Signature Dat e system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ' I 2 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e i 4M 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ or Cesspool privy is within 50 feet of a surface water P P Y ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh p P Y 9 9 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi I Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool E] ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 I i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 t Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Bridges Lane Property Address I Thomas Bianchi Owner Owner's Name information is North Andover MA 01845 04/29/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: i Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: See Attached Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes El No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 1 , ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town 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: Soucy's Sewer Service Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: Maintenance and Inspection Type of System: ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is North Andover MA 01845 04/29/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Approximate age of all components, date installed (if known) and source of information: i Were sewage odors detected when arriving at the site? ❑ Yes ® No I Building Sewer(locate on site plan): Depth below rade: 16" p g feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): I Septic Tank (locate on site plan): 10" Depth below grade: feet I Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 38 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape and sludge tool 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 thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Bridges Lane 'M Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 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 leakage, 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. CityFrown 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 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" Box replaced prior to inspection. See attached permit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Bridges Lane M Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: (1) 25'x43' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i �\ Commonwealth of Massachusetts Title 5 Official Inspection Form ' Is} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Bridges Lane Property Address -- — Thomas Bianchi Owner Owner's Name information is North Andover MA 01845 04/29/13 required for every --- — ---- - - - -- — page. City/Town State Zip Code Datee oof f 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: I ❑ hand-sketch in the area below ❑ drawing attached separately n � rc ✓.K �. .. 3C p P 13 3 3.% I I j i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Bridges Lane M Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Dug hole with auger in low drop off area, 5' no water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts i W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for every North Andover MA 01845 04/29/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _ . Map-Block-Lot • ���.,,F:,,,,H� Commonwealth of Massachusetts 104.D0071 BOARD OF HEALTH <k. Permit No • � ',y ., t;� y, . BHP-2013-0625 K North Andover P.I. FEE $125.00 JResr n4 F.1. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Soucy's Sewer Service to(Repair)an Individual Sewage Disposal System. at No 20 BRIDGES LANE as shown on the application for Disposal Works Construction Permit No. BHP-2013-062 Date A 23, 2013 Issued On: Apr-23-2013 BOARD OF HEALTH r 0512212013 $105.64 3170464 04/22/2013 12112/2012-03/14/2013 05/22/2013 20 BRIDGES LANE BIANCHI, THOMAS J. 20 BRIDGES LANE N. ANDOVER, MA 01845 PREVIOUS BALANCE $89 . 99 PAYMENTS THROUGH 04/10/2013 $-90. 01 ADJUST. THROUGH 04/10/2013 $0 . 02 INTEREST AS OF 05/22/2013 $0 . 00 BALANCE FORWARD $0. 00 36388103 397 ACTUAL 03/14/2013 24 92 WATER USAGE 24 $97.82 ADMINISTRATIVE FEE $7.82 36388103 373 ACTUAL 12/12/2012 21 91 36388103 352 ACTUAL 09/12/2012 66 92 TOTAL $105.64 36388103 286 ACTUAL 06/12/2012 36 91 WATER RATE: FIRST 20 UNITS $3 .80 OVER 20 UNITS $5.55 SEWER RATE: FIRST 20 UNITS $5. 95 OVER 20 UNITS $9.24 BYPASS METER WATER RATE: ALL UNITS $5 .55 3170464 04/22/2013 20 BRIDGES L_A_NE gct1801 NoAndWtrSgls T4 P1* *'**AUTO**5-DIGIT 01845 0512212013 $105.64 BIA_NCHI, THOMAS J. 20 BRIDGES LN NORTH ANDOVER MA 01845-2225 00004148552013000000000000051,70464040317046400000001,0564009 Commonwealth of Massachusetts � RECEIVED Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '�� 0 9 2��3 TOWN OF NORTH ANDOVER y 20 Bridges Lane HEALTH DEPARTMENT Property Address - Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 5 every page. City/Town 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 A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil James Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 X017 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Fu her Evaluation by the.Local Approving Authority 4/3/2013 Inspector's Sig ature V Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official 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 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every 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: i B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements, If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is . structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.. Y El ® N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Sutisurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y( 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. City/Town 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): ❑ brokenpipe(s) are re laced Y N ND (Explain below): P ❑ ® ❑ ( P ) ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•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 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. City/Town State Zip Code Date of Inspection B. Certification. (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or . more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D-box needs to be replaced & riser installed. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 3 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-11/10 Title 5 Official Inspection Form:SubsurfaceSewageDisposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 1-1 El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 p e the 9 system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field if an of the failure criteria related to Pa i ( rt C is issue Y ® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System. Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. CityrTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Ganonsr day y(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitarywaste discharged to the Title 5 system?g Y ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �c 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every 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: Pumped October 2012. owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,.volume pumped: gallons How was quantity pumped determined? . Reason for pumping: Type of System: ® 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•11/10 Title 5 Official Inspection Form: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 �r 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every 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: No as built plan, Testing was done 3/5/1984, design plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.8 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to tank. 3" PVC in house, no leaks visible I Septic Tank(locate on site plan): Depth below grade: 8 feet Material of construction: concrete metal fiberglass® ❑ ❑ g ss ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' 3' Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 8,. Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidecne of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date.of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Ofricial.lnspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. Cityrrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken&box partially filled with sand. D-box badly corroded. Needs to be replaced. Evidence of carryover. Evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts 9UTitle5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 25'x 42' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding; damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools.(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of'solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11410 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. C'ityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Oficial 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 20 Bridges Lane Property Address Thomas Bianchi . Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the-building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a A 3 O �h1-c t YI A- . t - �`kt a`- f o t a � t31 t. t5ins•11/10 Title 5 Official inspection Form P Subsurface Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells 4 Estimated depth to high ground water: 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: 3/5/1984 Date ❑ Observed site(abutting property/observation hole within 150 feet.of SAS) ® Checked with local Board of Health -explain: �I Design plan ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: i You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Bridges Lane Property Address Thomas Bianchi Owner Owner's Name information is required for North Andover MA 01845 4/3/2013 every page: Cityrrown State Zip Code Date of Inspection. E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 17 of 17 Town of North Andover Tax Map # 210-104.D-0071-0000.0 Parcel Id 16759 20 BRIDGES LANE BIANCHI, THOMAS J. 20 BRIDGES LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.02 Acres FY 2013 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until BIANCHI,THOMAS J. Payor 20 BRIDGES LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 17799.0-20 BRIDGES LANE Last Billing Date 1/3/2013 3170464 03 Cycle 03 Active UB Services Maint. Account No. 3170464 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 81.55 /1 UB..Meter Maintenance Account No.3170464 Serial No Status Location Brand Type Size YTD Cons 36388103 a Active ERT HH b Badger w Water 0.63 0.63 366 Date Reading Code Consumption Posted Date Variance 3/14/2013 397 a Actual 24 13% 12/12/2012 373 a Actual 21 1/9/2013 -68% 9/12/2012 352 a Actual 66 10/15/2012 81% 6/12/2012 286 a Actual 36 7/16/2012 73% 3/13/2012 250 a Actual 21 4/14/2012 3% 12/12/2011 229 a Actual 20 1/17/2012 -54% 9/13/2011 209 a Actual 47 10/13/2011 145% 6/7/2011 162 a Actual 18 7/20/2011 -53% 3/7/2011 144 a Actual 37 4/13/2011 50% 12/8/2010 107 a Actual 25 1/12/2011 -54% 9/9/2010 82 a Actual 56 10/15/2010 185% 6/8/2010 26 a Actual 19 7/15/2010 -3% 3/10/2010 7 a Actual 7 4/14%2010 -100% 2/6/2010 0 n New Meter 0 4/14/2010 -100% 2/6/2010 4274 r Replacement 15 4/14/2010 24% 12/11/2009 4259 a Actual 20 1/12/2010 -12% 9/8/2009 4239 a Actual 22 10/15/2009 -18% 6/9/2009 4217 a Actual 25 7/20/2009 37% 3/16/2009 4192 a Actual 21 4/29/2009 -14% 12/8/2008 4171 a Actual 22 1/20/2009 -7% 9/11/2008 4149 aActual 26 10/10/2008 31% 6/6/2008 4123 a Actual 18 7/16/2008 7% 3/10/2008 4105 aActual 17 4/11/2008 -61% 12/12/2007 4088 a Actual 47 1/22/2008 -34% 9/6/2007 4041 a Actual 57 10/12/2007 195% 6/20/2007 3984 a Actual, 24 7/20/2007 15% 3/15/2007 3960 m Manual estimate 20 4/16/2007 -12% 12/12/2006 3940 a Actual 22 1/19/2007 -64% 9/13/2006 3918 a Actual 59 10/20/2006 169% NEW ENGLAND ENGINEERING SERVICES INC November 7, 1997 North Andover Board of Health Town Hall Annex School Street North Andover, MA 01845 RE: TITLE V REPORT 20 Bridges Lane. Enclosed is the Title V report for 20 Bridges Lane,North Andover, MA. The system passes our inspection. This is a system that had a conditional pass dated 8/16/97 our File# 97-44. We re- inspected after repairs were made. If there are any questions please call me at my office, 686-1768. Yours truly, Z• Jamin C. Os ood Jr.,E.I.T. resident 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 E � r 7; Lid P 1 CO.MMONXVEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 0210E 61:-292-556O WrILU:IN!F WELD TRUDY COXE ��- ScactuS i ARGEO PAUL CELLLICCI N D JED DAVID B.STRUHS LL Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 20, 321oC•.C5 t^� v L , NO fI�DoUr/� Address of Owncr: D'ate of Inspection: (I( different) Name of Inspector: BERJAMIN C. OSGOOD JR. 1 am a DEP approved system inspeclor pursuant to Section 15.340 of Title S (310 CMR 15.000) t Company Name: NEW ENGLAND ENGINEERING SlIRVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 i CERTIFICATION STATEMENT I ' 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 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 _ &ndnlonalh Passes ! Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System !nspector shalt submit a copy of this inspection report to the Approving Authority within. 17- 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 bgyer, i(applicable. and the approving authorih I INSPECTION SUMMARY: Check A, B, C, or D4 AI SYSTEM PASSES: I have not found any information which indicates that the systern violates any of the failure c:-te-a is dtfined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the -Conditional Past 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 NO). Desaibe 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 Ceni(iote of Compliance (anachcd) indicating that the tank was installed within twenty(201 ycirs prior to the date of the inspection; or the septic tank, whether or no( metal, is cracked. structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection i(the existing septic Lank is reptaced with a conforming septic tank as approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z�� t 06 - .5 14 9,V0DcYC-1Z Owner: 12i[it ig,Qp Date of Inspection: "/ylt-7 B) 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 '('(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 thao four times a year due to broken or obstructed pi pc(s). The system will pass inspection if(with approval of the Board of Health)- broken ealthybroken pipe(s) are replaces ebsuvction is removed t I i t t i t Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require iunhe( 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 SYST�M IS NOT FUNCTIONING IN A MANNER t WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: i Cesspool or privy is within SO feet of a surface water Cesspool or pm-y is within SO 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 r ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 fee( to a surface water supply or tribut:{ry to a sunace water supply. - I The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. ' _ The system has a septic tank and soil absorption system and the SAS is within SO 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 i and the presence of ammonia nitrogen and nitrate nitrogen s equal to or less than 5 ppm. Method used to determine distance (approximat;on not valid). 3) OTHER I I (r—i-4 04/25/17) I P-9. 3 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIGlT1ON (continued) Property Address: 2O g R t D&4_s i—Al, Owner: /?t c kian o Date of Inspection: g i//10 7 D) SYSTEM FAILS: You must indicate either -Yes-or-No-as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface'of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above)outlet invent due to an overloaded or clogged S.4S or cesspool. I Liquid depth in cesspool is less than 6- below invert or available volume is less than 112 day flov.. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of trines pumped 4 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Amy portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a suriace water supply. j t i _ t Anv portion of a cesspool or privy is within a Zone I of a public well. Am portion of a cesspool or privy is within 50 feet of a private water supply well Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no r acceptable Nater quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysd for colriorm bactgria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] DIRGE SYSTEM FAILS: I I You must indicate either -Yes- or-No-as to each of the followin : i I ,The iollowing criteria apply to large systems in addition to the criteria above: The system serves a (acility with a design (low of 10,000 go or greater (Large System) and the system is a significant threat to public health and saiety and the environment because one or more of the following conditions exist: Yes No - the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the foal regional office of the Department for further information. I (revised o4/35/77) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2• B 2 t 0 6-t;s t_iq.v 4�' w. A,v p 0 V Cf— Owner: 1Z)( HA(2� ntt-S� Dale of Inspection: Check if the following have been done:You must indicate either 'Yei 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 inspections I AS built plans have been obtained and examined. Note of then ere not available with N/A. ' I i The iacility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste now. The site was inspected for signs of breakout _ o _ All system components. excluding the Sad Absorption System, have been located on the site. The septic tank manholets were uncovered, opened. and the interior of the Septic tank was in{pected (o'r 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 iacility owner land occupants, if dtiferent from ownert were provided with information on the proper maintenance of Sub-Surface Disposal System. ✓ _ Existing information. Ex.tPlan at B.O.H. ) _✓ _ Determined in the field 0i any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(6)) I (r—A—d 04/11/17) F.V. 4 or 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ZO G2I 0&C5 r..N, .v, „�p ov i e Owner: 2%c(gc l0 Date of Inspection: I 7 FLOW CONDITIONS RESIDENTIAL: Design flow: R.p.dJbedroom (or S.A.S Number o(bedrooms:-�' Number of current residents: h� Garbage gr-rder(yes or no%: Laundry connected to system lyes or no): '�L Seasonal use (yes or no):IV Water meter readings. i(available (last two (2) year usage (gpd): Sump Pump (yes or.no):,,V_ Last date of occupanc)•jC✓r/e�i I I COMM ERCIAUI ND USTRIAL: Type of establishment: , Design flow: 'p1lons/day ' Grease trap present: (yes or not_ Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary waste discharged to the Title i system: ryes or no)_ Water meter readings, ii available Last date of o�cupancy:i t t i t OTHER: (Describe+ Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of iniormation I I System pumped as part of inspection: (ye or no) Al 1(yes, volume um YesP ped: Qallo s Reason (orpurnping TYPE OF SYSTEM _�_ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (i(yes, attach previous inspection records, if any) VA Technology etc Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Tom.- Sewage odors detected when arriving at the site: (yes or no) y� rr..d..c oa/asirr) P.Q. s or 10 -------------- SUBSURFACE -----------SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: g` g k I pG.t s L n./, N. YEN O o Owner. r Date of Inspection: 2 c 17� /t'<<s c if f y��c7 BUILDING SEWER: (Locate on site plan) r Depth below grade: Z Material of construction: _Z/ast iron_40 PVC _other(explain) Distance from private water supply well or suction ILrt- Diameter y„ Comments: (condition of joints, venting, evidence of leakage, etc.) Eco-rex K F/10 M /NS/Or= Q/9SC�C✓I � I i SEPTIC TANK:_ I 1 (locate on site plant Depth below grade:_ Material of construction: _concrete _metal _Fiberglas) _Polyethylene _other(explain) If tank is metal. list age _ Is age confirmed by Certificate of Compliance _(Yes/Nol , Dimensions. / S GJ 1,6 -4.7.Al Sludge,depth 0- Distance Distance from top of sludge to bottom of outlet tee or bafflfe'.33. t Scum thickness C`` Distance from top of scum to top of outlet tee or baffle. 29 Distance from bonom of scum to bonom of outlet tee or baffle:ZO How dimensions were determined. 77-e Si7cK Comments: (recommendation for pumping, condition of inlet and outltt tees or baffles, depth of liquid level in relation to outlet invert, struoural integrity evidence of leakage, etc-) 7/`,vK /1 I I GREASE TRAP: (locate on site ptanl Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet ter or baffle: Date of Iasi pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural i integrity, evidence of leakage, etc.) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �J 2(D C,k s `/>t✓t, Owner: Date of Inspection: TIGHT OR HOLDING TANK: tTank must be pumped prior to,or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete_metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacrt\: gallons , Design flow gallonJda% Alarm level Alarm in working drderl_ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, e(c.) ' DISTRIBUTION BOX:_ (locate on site plani Depth of liquid level above outlet invert:_ Comments: ' (note if level and distribution is equal, evidence of solids carryover• evidence of leakage into or out of box, etc.) ' I I I r PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r—i..d 04/25/971 f.y. 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ZC 6 61 D&E > I-,v ,V f")jo0 04;:: V<- Owner: (Z kc "ri a a2 q .^n t s c Dale of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: i leaching trenches, number•length: ' leaching fields number.'dimensions: C11a 6 t(c. q00 Sa• 1 -T) overflow cesspool. number: Alternative system: Name of TechAology: ' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 1 � CESSPOOLS: _ (locate on site plan) Number and configuration Depth4op of liquid to inlet invert: ' Depth of solids layer: i Depth of scum layer: Dimensions of cesspoo!: Materials of construction: I I Indication of groundwater: inflow (cesspool must be pumped as pan of inspectlbn) ' 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: (rto(e condition of soil• signs of hydraulic failure• level of ponding, condition of vegetation, etc.) (r—i—d Ol/7S/)7) Y1.q. or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION {continued) Property Address: Z�- 62�d ,Up'),e 4 Owner: Date of Inspection: ^ `s SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I � i No�SC ! i V)H D f5T- Sok , 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2-0 g Q td Owner: lz-c ,c,-,,o ,A ,s C Date of Inspection: 7 Depth to Groundwater Z 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 e(c.) Determine it from local conditions r Check .wth !oca! Buard of health I i I I Checi. FEMA neaps Check pumping records i Check local excavators. installers ' Use USGS Data Descr-be .n voSr own words how you established the High Ground.-.•ater Elevation.!(Must be completed) 1). &Lr, I-fi t��-��Qi c{ 2c Z 3` bele., ��� w� "T I 1 `f-, 3 P.9. 10 0( 10 . NEW ENGLAND ENGINEERING SERVICES INC P August 20, i9>7 North Andover Board of Health Town Hall Annex School Street North Andover,MA 01845 RE: TITLE V REPORT 20 Bridges Lane Enclosed is the Title V report for 20 Bridges Lane,North Andover,MA. The system conditionally_passes our inspection. If there are anquestions lease call me at m office 686-1768. any P Y > Yours truly, *ean'n C.Osg dJr.,E.LT. 33 WALKER RD. - SUITE 22 - NORTH ANDOVER,. MA 01845 - (508) 686-1768 COMMON\VEALTH OF MASSACHUSETTS y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r' DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 617-292-5560 WILLIAM WELD SCM COXE Govcrno: Scactan ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address- ad aQ`oc ,zs I-tiwtz, �v ' �h 0'"ed1_—Address of Owner: Date of Inspection: $ I Ito Ct'j (If different) Name of Inspector: BENJAMIN C. OSGOOD JR. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 CERTIFICATION STATEMENT I cenify 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 t�Condrtionalk Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: ` Date: ftP 1 The Svstem Inspector shall ubmrt 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 De partment of Environmental Protection. The originalfinal should besent to the system tem owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: s- I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CK4R 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B1 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. I('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 refiltration cij xfiltration 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. (r—i—d 04/]5/97) pa4. 1 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: v� e%D&V S k t460 V) luo k1,tW v'L- Owner: e i G'h Kit 6C ` Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) /V 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 pipets). The system will pass inspection if(with approval of the Board of Health) broken pipe(s) are replaces obstruction 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 WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well. unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the ,presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. .Method used to determine distance (approximation not valid). 3) OTHER (r•vix•d 04/75/97) Pay• 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: c�0 1—W,121 00 A-1400 p K� Owner: VM 1 �L 1 Date of Inspection: 8/ftol � � D) SYSTEM FAILS: You must indicate either "Yes" or "No- as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution 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 float. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Am portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any porton of a cesspool or privy is within a Zone I of a public well. Am porton of a cesspool or privy is within 50 feet of a private water supply well. Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis for coloorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No` as to each of the following: The following criteria appl.• to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or morg of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner oro operator of an such system shall britt the system and facility into full compliance with the groundwater treatment program Pe Y Y g Ys N P requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. I (raviaad 04/25/97) Page 3 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:do a e�-o a-67S �,w-ja, va 1�wLJP.'L Owner: m i S L ` Date of Inspection: Check if the following have been done: You must indicate either -Yes- or 'No" as to each-of the following: Yes No J16-- _ Pumping information was provided by the owner, occupant, or Board of Health. V _ 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 pan of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout ✓ _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field Of anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J (z.vi..d 04/25/97) paq. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I Property Address: a0 1rOW- ' t9 w tZ N J 11—L&0,1,p,dL. Owner: rK SL Date of Inspection: g ) It, [ q-1 FLOW CONDITIONS RESIDENTIAL: Design flow: e.p.d./bedroom for S.A.S Number of bedrooms: Number of current residents: Garbage g,,r der (yes or no): � Laundry connected to system (yes or no):4- Seasonal use (yes or no):-(L Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): A/ Last date of occupancy: a U_e"i 1 COMMERCI.AUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (ves or no)_ Industria( Waste Holding Tank present: ryes or no)_ Non-sanitary waste discharged to the Title 5 system (yes or no)— Water meter readings, if available Last date of occupancy: OTHER: (Describe? Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information: v—P zOa y gikj?.S (rU LOwnYl, System pumped as part of inspection: GFor no)_ 1(yes, volume pumped: ------_gallons Reason for pumping _ TO sPo c 'Tv��t ll TYPE OF SYSTEM T Ae"'ieptic tank/distribution box/soil absorption system Single cesspool r Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (i(known) and source of information: /J �/elgQ <�}PPeax Sewage odors detected when arriving at the site: (yes or no)—P0 (reviled 04/25/97) page S of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ')�D �2� )Gids t(I r fel U vt�✓e tZ Owner: S L Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: ✓cast iron _40 PVC _other (explain) Distance from private water supply well or suction lire / i Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) J-Oo KS b K 12Qo"< •ut s ; Ori SEPTIC TANK:_ (locate on site plan( Depth below grader Material of construction: Vc—oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 1,300 6-4 L Sludge depth: _ )/ +� 1. Distance from top of sludge to bottom of outlet tee or baffle: y��l J S © K L moi! Scum thickness: � k ig Distance from top of scum to top of outlet tee or baffle: M e L)le fr'2 e-,,t S Distance from bottom of scum to bonom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) _1 K A��o O S To ��� Q+✓P t-A G s=' (� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) i i i (r.vi.•d 04/25/97) P.g• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �i U �� D G 1t S ME�j ..t to v e i Owner: (n i SL Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design floe. gallon/da. Alarm level Alarm in working order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) 11 ++ � I 1 _ Depth of liquid level above outlet invert: U-+1 t'z#t LP Col V V er�iC�, SGU 1-11�V!��- T �'t-yev Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Sox I��s (VoT 13ttZfy 2eKG (�3 oi= PUMP CHAMBER: (locate on site plan) s Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r.vi..d 04/35/97) P.q. 7 of 10 ' ct`)Yyy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:a0 6 e_;'0 (tie2 5 L4) Owner: ' I,$.G � Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: ) leaching fields, number, dimensions: Oh! overflow cesspool, number: Alternative system: Name of.Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, conditionof vegetation, etc.) ijerm o(z fCv" v oa U S $ T��+t Ajt?T t3 r'z IV CC_aLV:-1 gj,� Low CESSPOOLS: _ (locate on site plan) Number and configuration. Depth-top of liquid to inlet invert: Depth,of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) r- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i (r•vY...d 04/25/971 P.q• p of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:a0p`2-- Owner: ` PYL rSG Date of Inspection: 811('1 �7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I � (revised 0{/25/97) p►9. 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: p ' 41 Owner: &I i SC i Date of Inspection: Depth to Groundwater 0-1-Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) ✓ Determine it irom local conditions Check w!th !oca! Buard of health Checi. FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in .our own words how you established the High Groundwater Elevation. (Must be completed) A e.Ar S I'}2 t Z Loma. cC, 1-tk%A PC Lit, 2 -[u+;e t a t ' `�o O IF: j!.,t9 t- a v L l i f, {� 3 R$0 V otz4- .,r>Rt, Gff � (r—vial 04/25/97) P-y. 10 of 10 I ' I Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH November 6 19 97 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (X ) D— Box Only by John Soucy INSTALLER at 20 Bridges Lane SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. NSA dated 19 . The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH Town of North Andover, Massachusetts Form "°'a BOARD OF HEALTH NORTH 0C T. —19A DISPOSAL WORKS CONSTRUCTION PERMIT ' �1SS^cHuSE� Applicant f TELEPHONE ADDRESS Site Location jIA-kA zoix� 67 Permission is hereby granted to Construct ( ) or Repair (z—}-am Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. ' CHAIRMAN,BOARD OF HEALTH Fee 7-3 _ D.W.C. No. fir- - APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 1ACURRENT INSTALLER'S LICENSE# LOCATION:_ yo� LICENSED INSTALL f- 0 hA C SIGNATURE: TELHONE#r ' CHECK ONE: PAIR: NEW CO STRUCTION: (Wscq�qo ';:�eec IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-built? Yes No Floor plans on file? Yes No Approval _ �. � �� � Date: /!� ` FROM SOUCY'S SE6ER SERVICE INC* PHONE NO. Nov. 06 1997 02:23PM P3 Xv` •a� .a ara r,. �'�����,�:.,,a�`'�"-rr _ ��� s':';z?'==�:kc::'s�.�i`^i,r�;� a;>�,yy��``t�a-,j.,`..;,.,. .r�,sawr•�. `,..:,�:. ..•yY�„s:.�.. ': �r • � .n.i t'ta::. Vf�:':1:�'.',r.�w:?Y,f: J.:. ....:, . •'�, - TcJvr,',' .i ' #�. C�,s•., _Y�Y:. flA,,. _ .�'.,vt,.,!'�i:`:.: a ,�.. 'F';'�.�yF:^^ .•Fw�6{';cz3' ,'�.• � 9;';•. :if y`w1 i'?jN,” 'ar,'��.-•�,,, r\^• ...'S.-.;,}r._ .:�\�`�..K,--�' 'I'a�"4: , y'�e;•.Sa.:Ax .2• iv. Y"�:te:�:.C�'..' _bri.�:::}.7:h}ice;'. ,y, �•. r. �' •.i. `i.. .,� fv.-�•!��"., •`fr": �.a 'Si d!�'r,���:''r'�'y''t�,e''`R'Yfi�rS,;t.�:.�"`.y?:i^: ��.;'t.J :\s_. �.vn"!;':,6?1�, y i'.''•''�• ro� ,�.p'1,d.,•�,:A,s;,:_:y�.��a,^,,?."'N�Ct''�:•. ^v' ':S•••' &1' - :i�:;)!fT":!i '1at�."yr''f' .�'c:��. ''f;i•;. �ia"4A�,;n:' ��+ �< �.t:'T:.' 11 �. ;t.r• •, rh' •.Ff C.,:..(, .. .SLG� �iA „'1 .l}' ..'4-�.7aJV,h�_;' r`,�•:e'sl�K..,M-fir is"'.. . Yza";:wr.�U' - .'.yf Fp'�;Iv'•n+C,ya. Vr;t ' �Jj::�i2w�k. •�ij i.i' •..L4:�.�,e'j•.....• ^ '�• t �•- � r hp::i:�:,nA'c:: ,;I: .i'Y•- �E-q«.'`f;� �,bN �7(;i-rtv: .�3�"'�Y�7.�?,�i k•':'^ 1",' "•`�"• �r+ .::9� .�.•�� ^'�.-= .'y,.iiaL'Sn"w)f�� \,��-,�M1r va� '� .'• µrt.•"X{i�:. �`�. � (. -,irr=Y',,�y'-., rr ,ki Board of Health SEP'T'IC STSTEK North AndaverZHaas. INSTALLATICK CHECK LIST LOT'S . 5 AP OVED DATE DISAPPSUJED X AVATICBi OK ��IL 1 L-ZL i 4, t-2tf eaFemnst FAIL OK 1. Distance To: a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe 4. Septic Tank a. Tees -_Length do To Clean Out Covers b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers.& Box - No Cracks b. All Lines Flo Ang Equal Amoimts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth _ c. Capped Fads d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees l e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Ili spo sal 9. Y nal Grading.Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location - --------- b. Dimensions of System c. Location -with Regard_to Pere Test d. Elevations e: Water Table r Mkv: cif hEalth Si t.:. r�FACE DISPOSAL DFSIW, CHECK LIST •LOT f t $Qm4S DISAPPROVED DnTE - APPROVED DATE " Reasons: -Provided: ) l Title Y FAIL OK Q� Reg 2.5 The sol' It-: plan must- show as a 1ni n4 m,L; the 1011 LID be served-area,c ca,��i_ozis lot ,ahn ttF l acy and log deep observa u-on holes-distance t' ca LI)o,, and results percol.a'_i0n tests-distance t t' -sign. c4lcnlations & calculations shmving reou3: . ' 3 ' 'ng area r e _ocats�n Md dimers ions -of s;,s'�er-includ3ng ex3 st Tt and prcapased contours g) locatic , any vet areas -Ath-n 1001 '-of sewage dispo {,em or �r (tf.scl.=i-n_�r-check--iiatlands rapping r face drains within 1001 of seg �s c'' �1 '19a :M s�ar fa�'Y :�.0 sLL�iJsdr,,, a SyStci�l Q." d�s�'311Lt locat,f!., any- drainage easec nA0 ts vithin'11 of sc' osal disclairer-Pl zrji i_ ; Board files 3) kr!0_,-j .- :aces of rater simply uittdn 2001 of ser��c + -.r discla ner k 3.=_,� of any-}proposed veil to serve lot-1001 f ..; `ring facili lc ca . of mater lines on from le-.' ..r u lnc� of benchmark o) disposals no P r i,, be used in construe tion 4) p't,'�'1- (-,r system-elevations of basement., plaMhs 11_':, ,tic tank] I', ,,~,ion box inlets and outlets, distributio; 1^, �_ 'ring and f7 tis�:' �,1�:rations r,�xi: round mater elevat3 on in area s ,,age d{ S) pl ,r, r i. be prepared by a_Pro`essional Bagineer c' p]-olt - '-ral authorized by 1 r w to prepare such p_ (a) c :,; .. y-150 of f1o�;� ��,.:r table, tees dear r s acs:: p�.ping cellar jmll or s --ng PO'01 d) 25' ;, subsurface drains Reg 10.2 't. tion Foxes s3c , .afar than 0.08 Reg 10.4 b) C,,l�ilL �r.Y J. �►.� SZ1�'E'�� 'TLG� ' Uri., "" a Check List 2 ti OK Leaching Pit s Leaching pi.L.; re pi��. i is possible 11.2 a) calculations A. each V 1�' .4 ( b) spacing 11.10 ( c) surfac r, ;e 2% 11.11. ( d) cove materR:L ( e) �� 14 a, ,7 '� pad i f) a at elbow ( no bends in ',:e fro:~ v..)3 Leaching ..: �s 15.1 ) no greater C 20 mi h ( area-mfnirx -4 .:0 sq ft 15.4 i cons ructicri ray' field 15.6 ( ) surface dr .' 7,3 2 % 3.7 1 e) 201 -from c`,i. .`= vim. ct -d Leach3nfi: .1.is ?�3.1 a) c c ozi.. F)i, each-'- zz_ ft ?_!t•3 i b) spacing-4 f _ .� 6 ft -. '' : . 4.4 ( _ c) dimensio d) cons ction 114.7 I ,e) S e- y_�;. 0 i f) dace cl ��, a 2% Dow ahill S?f•P e s ope;Y x= i: be shJ .a) I i ) Y/x X 150 bs shU.-a) Ps _. . a) agproval 0.6 ( b) stand-bar j <a _ 1�OL"j U SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No r i�C� t'/ Lot No Loc/Subdiv. Pland / Owner Investigator Observer f loe � SOIL PROFILE DATES 1.Elev 2.Elev 3.Elev 4.Elev 1� 0 w 0 0 0 �c 1 1 1 1 Timms Pits est 2 2 2 2 3 3 3 3 4 4 4 4 5 \ 5 5 5 6 6 6 6 7 7 7 7 a 8 8 8 8 9 9 9 9 10 10 10 10 V-,o UjCxj er- 10.o• Benchmark Location Elevation Datum PERCOIATION TESTS DATES A\0 Pit Number 1 2 3 4 Start Saturation W.30 So ak-Minutes ` ar e Drop of 3"-Time Drop of 6"-Time L Mmns.lst 3" drop < y� Mins.2nd " Drop (� PercolationlV .�F � t SOIL PROFILE & PERCOLATION TEST DATA North, Mover, Mass. Street No �fi Lt Z> (..4&Sm. Lot No Loc/Subdiv. Pland OwnerJ�'`i C. co Investigator Observer SOIL PROFILE DATES 1.)E1ev 2.Elev 3.Elev 4.Elev 0 0 0 0 1 1 1 1 Timms Pits est 2 2 2 2 31 3 3 3 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 8 8 8 9 9 9 9 10 10 10 10 Benchmark Location Elevation Datum 1 PERCOTATION TESTSp DATES -7 ► (81 7L14 7 14 7 4 Pit Number 1 ��� 2 c} 3 4 Start Saturation (l* SS 1'Z%3o z.;30 Soak-Minutes it l 11-- so 12:.45 iZ;.4.6- Start e 1 to 15" 5 Drop of 311-Time W43 •,os lz o0 M% W Drop of 6"-Time 2:0� Z••'� 1; S OS Maas.I.st 311 drop 'L- ► lS S' - Ydns.2nd " Drop Percolation C1g S 1 �u 3 •„r��..sri.r.rxxrr*a�waw _ . 7'-0.p On -. Ir ID 0 r _ w L r /V'D 4 y .G E[, R x e1v r, P�eDPOSED Sus sine F•�GE SEWAb a. b/sxas 6 SYs rEA? Amo ' � PrPOPOSED LOT �TRAD/.�/G 44rE :. 3- 9 `8 4 v REVISE D 1 -,,'1'7- F'4 AVE /f�tL�AS/EI'Z Loc.a rio�v -Lo 'f` i DES/G AieR • Go�MON WF 1I vroSEPf,/ cT 3 IDC'E -ylE*� - WESTK/A�d CIRCGE y it„ Y.l TEL. GG -4983 TAR, Wyk �.:,,��~.�.!.1-� ��� ---• ...., - . .. .'."� .,-,„ter L.• QES/GAJ DATA T YPE OF Bu/LD/r 14w: 4- 43•Rc�- a $EMIAGE FLOW EST/MA1E: 6'.n c G P D `' =- -- SEPT/G 7 4,Vl< /5 �6 c� r i4556,EP7”/40N AREAor /•7x Gooc-p /010 s F RF Gts /o S'o S•.c Q5PERr01_Ar10,v 72F:sT3 m/ arZ Avg 4*4 A04 mc, 7-/1-83 --/If 7-/9 -83 7-/19-84 ��`✓3 z TLS' KE!/Ar/dN 13 --- � � �G t��' �� ;tr.5 E f•tv� ....,_ •`� .d�OrrnM EtE✓ATit7N ✓ s , 2 r r �l y %%MAQA T/OA/ / AfIAJ. 17 MIA-1 Is 1 i3� /I rb 9" DROP 4f/A/. 1-r M/A/. /•r Mil• r M/N. i 3 ` _ s \ !"rb G" ORoP I/ ,cf/N. ;L,5' 4f/A/., a MIAZ ! ` `' ,4 AKOM04A r/OA/ RAIQ 41 /3 ~'- •. .� + 49 O TEST PITS / 4*1Z *'3 �¢ l t` DATE !- 13 TOP ELEVAT/DW SO/L TYPES SuQSO✓C. $kbSaiL AA/0 S�S�ydy S'CLay�y ' 13 ^� R" WA MR- rA8LE *ILL 8 6 r NO NZ.' ° LL LOCA r/0 All ��/ � -••- `�' � �>< t a 7.35 �� 8•o 64TTOM ELEt/Aria,vi /2 SS >;L r S c5 C,Q,R/ TE57� COVaYC7-EL BY' R/4RZA&A110 1511A Sao ENG • TESTS bv/rA/ESSEL BS' Cu T % 932 PLA A/ e•� .DECSIC7" LA?/r&_le/A c S' EE T r iAerllRrJtl�lO1YC, ti�7�/N�fr.IiNCMt►I.AR#[MLMM.MG,W..N.NAI:.rIKn wR llf•vwxl�9r.Il.vf/b.Y.lefv/wl►,ril..N.7nlxAawr�raefY tflnsMwJaV.ar.rhr uw�,vr��x.rnurwna.�r•rn..a.r,.s•.•.r�r.uw.n.:wwOrMlr�w�.r.www.iwwrv.rw.t�.rn.rw.,uam�vaxsxlnYtll'il��ia• �.-..r- r _i I ••3�f 1 - , - - • . •_ . . .- . .• . �''Y' �E.•�cEO ���t/r, �So�/o P�/.L^. PAPE • O -� Dole TED f?l/C. P/PE COAL Ec?u/vAcENr) PARr114e— BED END SE Aj Foe 5PECIF/C.4 T/ONs - SE6 sECT/OA! .4T LOWF2 2/GN7-) AecA- f o So j-1, ti. /300 4M. CONGQETB SEPT/C TAMK , 4"� LRF. P.�c. , s oas• .�BSO.ePT/ON �EO /SGA AY /UDT TU c e,4LE 40 _ 137 too - t3� - t3� 50.el ioT - - •• CKFILC.. - - c•r 133 Ole • - � . w W w` 1 $- • =�- • •' �•. •Y C,2USNED STONE �+ `� „ .Fil 3In rp / Wi4SNE0 Q ti \ Q � /GPl/SNED STavE � O � • TO MEET .1-A•5..4.0. � _ �>�• :MPEG'. r-//-�oJ !14 _ . i13 A �IBS:JE'PT/ON BED cS�ECT/O,U PIN- 69. F/LE n J7 ,_xA1E yo-e. r"=40" l�Eer. � �"� PRDF/LE AN[3 �iBS�.ePT/O!v E�E� / ��ct! �rVt� J�EC7-/ONS v�`F