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HomeMy WebLinkAboutMiscellaneous - 20 LACONIA CIRCLE 4/30/2018, '. Lot & Street a 6 L.A C(9 )I A CL,, Map/Parcel 106,011,10- CONSTRUCTION 66Q I�- CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# l0 9 Plan Approval: Date: Approved by: _ / ler Designer: S Q'0 P.5 d Plan Date: Wil/It-2 --7 -1 .V Conditions: Water Supply- Town ._... - Welh Well Permit: _Driller: Well Tests: Chemical Date, Approved Bacteria I Date -Approved Bacteria II Date -Approved Plumbing. Sign -Off. Wiring Sign -Off Comments: Form "U" Approval: Approval to -Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? Well Construction Approval? Septic System Construction Approval? Certification? Other Any Variance Needed? FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: YES NO YES NO YES NO YES NO YES NO YES NO SEPTIC SYSTEM INSTALLATION Y Is the installer licensed? -YES ` NO Type of Construction: NEW p New Construction: Certified Plot Plan Review YES --Floor Plan Review YES NO _— Conditions of Approval from Form ti YES NO _Issuance of DWC permit: NO DWC Permit Paid?� — NO --DWC-Permit #_� Installer. Begin Inspection:.YE NO -Excavation Inspection: --Needed: .._Construction Inspection: Needed: As BuiltPlan Satisfactory: YES Approval of Backfill: Date: ' ,/ By: ---Final Grading Approval: Date: l ` / y V By: v/' r f Final Construction Approval- Date:,L//;/c' By: Certificate of Compliance: Approval: i,� Date: 11115 1 _ Commonwealth of Massachusetts RECEIVED City/Town of a _ NO V Y 3 2008 a. System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front, left rear, left side of house. Right fron(right rea , right sid ou . Address�- Cityrrown State Zip Code 2. System Owner: fZ�C),A,,_ Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: 0 Other (describe): State02�r� _IZi 0 liTelephone Number ` (Q tQ Date 2. Quantity Pumped Cesspool(s) = eptic Tank Gallons Tight Tank 4. Effluent Tee Filter present? 0 Yes Lam' No If yes, was it cleaned? 0 Yes [] No 5. ConditionAste� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: 1 1. - - Lowell Waste Water of F 5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of I RECEIVE® System Pumping Record T Form 4 FO006C2 4 2 4 v DEP has provided this form for use by local Boards of Health. rff,"Ile ord must be submitted to the local Board of Health or other approving a A. Facility Information Important: When filling out 1. System Locati forms the j compute r, use only the tab key Address to move your kc i,-' cursor - do not use the-retum City/Town Stale Zip Code key. 2. System Owner: 4 Name feQ"' Address (if different from location) City/Town Sta Zip Code -7- (60 Telephone Number B. Pumping Record 2. Quantity Pumped 1. Date. of Pumping lS� Date Gallons 3. Type of system: ❑ Cesspool(s) -f�]Septic Tank- ❑ Tight.Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes B No If yes, was it cleaned? ❑ Yes ❑ No 5. Condit' n of System: n✓` t (a-jj (A- 4-z7w� 6. System Pump um By -Name Company ... -- Vehicle License Number 7. Locati here conte weosed:. Sig toe f auler Date http:l/www.mass.gov/ p/ at /approvalslt5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of t NEW ENGLAND ENGINEERING SERVICES INC August 24, 2004 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RECEIVED AUG 2 6 2004 TOH _ALTH DEPARTMENT R RE: TITLE V REPORT: RE: 20 Laconia Circle, North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely g C Benja�C. 0 g , Jr. Certified Title 5 inspector 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 J COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 RECEIVED AUG 2 6 7nn4 TOWN OF Nu") h ANDOVER HEALTH DEPARTMENT OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: a O 1^14 Ca'o , V c, R /u,3 all-( L -,0 D 0%jfA, Owner's Name: T"t-i olK 4 y �r— 2 i E L Owner's Address: 2 o L -A -co ,v • ,a, Gi 2(tj5- A 90 i t -C A -,j D n,,� Date of Inspection: _ R i 21( OV Name of Inspector: (please print) Beni aurin C. Osgood, Jr. Company Name: New England Engineering Services Inc. MawagAddress:60 Beechwood Drive, North Andover, ILA 01845 Telephone Number. 978-686-1768 CERTIFICATION STATEMENT I c artify 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. T am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: Z o The system inspector shall submit a copy of this inspectiazd to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection, If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 4 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 L,+c.D &v k A-- c L a.(- tV (LZ t A4� D e-),, C.-. .-t ,+ Owner: _ t o rK✓1 S Flt EL - Date of Inspection: 01 Zt ( D � Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. em 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: _&j_ One or more system components as described 'm the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the Existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a ym due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ND explain: broken pipe(s) are replaced obstruction is removed Page! of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress: _ 2� t_� LDN c t acLir Owner: S r—&) E +_._ Date of Inspection: C. Further Evaluation is Required by the Board of Health: 1V—J 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ` Cesspool or privy is within 50 feet of a surface.water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 fee_ t 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 colifoM bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. Page 4 of 11 OFFICIAL INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address; ZO L -6C6 tJ k (+- C<124Lt,C D g?t•P Am D D,)e/L 4,4 Owner: -r( p Iv, 6 5 FR i EL Date of Inspection: al2tj oY D. System Failure Criteria applicable to all systems: You must indicate `yes" or `no" to each of the following for aIl inspections: Ye$ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/s day flow ,/ 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 within50 feet of a private water supply well. . Any portion of a cesspool or privy is less than 100 feet but greater than 50 fed from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less tiian 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303, 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 1pd. You must indicate either "yes" or ` ne' to each of the following: MKfollowing criteria apply to large systems in addition to the criteria above) yes no _ — the is within 400 feet of a surface drinldng water supply- — the system �w�iOO feet of a tributaryAo�`surface drinking water supply the system is located in '" en sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a publupply i' If you ha ed "yes" to any question in Section a system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The o or operator of any large system considered a significant threat under Section E or failed under Section D shall de the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional off _ of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _ a. o LA c o N %'q C-1_,ZC-C Acti s7 0,,je/L .tq r+ Owner: Zoo M ri s i 21 CL Date of Inspection: ej 2 _ 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 ? ZWere as built plans of the system obtained and examined? (If they were not available note as WA) ,z_ Was the facility or dwelling inspected for signs of sewage back up 7 — 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 thebafflesor tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?. Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes/no mg information. For example, a plan at the Board of Health. — Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) 1310 CMR 15302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: t.t -A ►ZCLC ivy f?i?t / o Qljek i41+ Owner: ri t o AA s Fit i EL Date of Inspection• . —e Z i .o !. FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _�_ Number of bedrooms (actual): DESIGN flow based on 310 CMR 15203 (for example- 110 gpd x # of bedrooms): H g o Number of current residents: _� Does residence have a garbage grinder (yes or no): ` &:y Is laundry on a separate sewage system (yes or no): J [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): W Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): _AZt> Last date of��— car: G,.l r rG•r---------.---_--- --- ---- COMMERCIAL/INDUS'TRIAL Type of establishment- Design flow (based on 310 CMR 15203): gpd Basis of design flow (seats/persons/sgtetc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Z '�o 3 b `aR PC2 Dwnig- Was system pumped as part of the inspection (yes or no): ALO 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) _ Tight tank _ Attach a copy of the DEP approval _ Other (describe): — - Approximate age of all components, date installed (if known) and source of information: S w ecus oto A -;!c a u, CT Were sewage odors detected when arriving at the site (yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 %acLe Owner: 71 d o �t A-5, f�1 I CL Date of Inspection: P,j 2-1 Dy BUILDING SEWER (locate on site plan) Depth below grade: Z4' Materials of construction: cast iron L/40 PVC other (explain): Distance from private water supply well or suction line: 4- Comments (on condition of joints, venting, evidence of leakage, etc.): C' l '/1 e� L 00)1,, 5 r11_w %.— o"t 5�.•�tGri SEPTIC TANK: _(locate on site plan) Depth below grade: Material of construction: to mcrete metal fiberglass _polyethylene e er(explain) is mewl list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: / Sludge depth. Z :Distance fromtop of sludge tobottom of outlet tee or baffle: 3 Z ` Scum thickness; 7 -- Distance - Distance from top of scan to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: t z " How were dimensions determined: -1-7c ti Comments (on pumping recommendations, inlet and outlet tee or bade condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N14 _ i.v &-Oop CO- 0 ZJn. Lck 40 POC 15-17 iN C -r-6') V ,7) J N c' IC -e f%2 C vy, ei -,) ae 414C c ►')-t 4 -:f - GREASE TRAP:A4 (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 umpingComments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc): Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2, c) LA -co N A- c -c &( L, C 4j)4 PRS o ��- Owner: t o M. ✓� S �c ie Date of Inspection: TIGHT or HOLDING TANK: Ll -(tank must be pumped at time of inspectionxlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: - Capacity: rallons Design Flow: aallonslday Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping- Comments umpingComments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be openeVocate on site plan) Depth of liquid level above outlet invert: C,) • 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.): RZZ)x IN (911 (O� i1JA CO ) R r rcCl�e C� v i2eC�MC.cJ'— PUMP CHAMBER: ry i � (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc ): 11 Page 9 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ;Za Ct2GUe� No (L -,-,h 642DnofA AAA Owner: 6t -16C, Date of Inspection: ;3t SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leading fields, number, dimensions: i overflow cesspool, number: innovativetalternative system Type(name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): i'� O F Q a K -S n o t-✓rLcz L, AZO i o Nay 1'1 Cr aAi+V S V / �� .2 Ary 3c4 A err 065' -6 --EZ! M-^ CCSSPOOIS: &A (cesspool must be pumped as part of inspectionVocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scam layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, edition of vegetation, etc.): PR1VY: NA -(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): Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2- L- Aco j, Q c, Q c c e Owner: TH 0 nn, 0-s Ec. Date of Inspection: e172jo, SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ,f®'f Page 11 of 11 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2� L A -co yF C , z tC Owner: _ - 4144 S f: -y4 G -L Date of Inspection: ► 2• `, SM EXAM Slope ala Surface water AJ Check cellar Shallow wells ND 5,,,•p 112Ay in Estimated depth to ground water b feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed, 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) entation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: A-73 0 X E (r K J viv ✓� v i • o �y E o Ln 3 LL 01 U L' 0 .. CJa LA U L rte-+ � C) N ... W .. D , C7 U " U Q . •Fd i InLn ro W LU n Vi ro lL a O .... ro _ V rt F- J d m in ro Q D. ro O LLI Z� L .. LLL L L O - - �O o �� J T o - a Q WO n Q o� O " iz Q/ N [� N Zr a> rsd 0 0 Q U t N o 0 Z m LL.ro m O O U 0 u Z °� F- + c ro a ro = U L_ O L •r-' " Q CL U N _ U ro U O .. y 423 .y iF > (/1 cu ri y TOWN OF. lam- "lNi_-UVE2 SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (k) repaired; by _ Z 1AM1/S /NC located at 2a �' CU/J/14 42/,e was installed in conformance with the'/4/e hV 16V2'4oard of Health approved plan, System Design Permit # f � , dated _? /Y d _, with an approved design flow of 6 � 2,5 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the inial grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Installer: Design E Date: Date: F /7 Town of North Andover, Massachusetts Form No. 3 NORTH BOARD OF HEALTH 1+ OL 19 O � F A DISPOSAL WORKS CONSTRUCTION PERMIT SSACHU`�E Applicant DAME ADDRESS ` TELEPHONE Site Location ak—r—� Permission is hereby granted to Construct ( j or Repair (t4 an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. /D 9L CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. /1) 3 ,Z APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: ` CURRENT INSTALLER'S LICENSE# LOCATION:_ 49 Za c6^;6, O r. LICENSED INSTALLER: J� Z -77,, SIGNATURE 'L. ; TELEPHONE# 4 7 7 CHECK ONE: REPAIR: �� NEW CONSTRUCTION:�G 5 IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes f"� No Yes No Floor Plans? Yes No Approval Date: Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES ii School Street North Ando%er. Massachusetts U 184 SSS ��HUSE� \VILLIAM ! SCOI-I' Director July 13, 1998 Steve D'Urso 22 Lilly Pond Road W. Boxford, MA 01921 RE: 20 Laconia Circle Dear Steve: This is to inform your that the proposed plans for the site referenced above have been disapproved for the reasons below. 1. Names of abutters missing. (NA 8.02j) 2. Not all distances shown on site plan. (NA 8.03a -c) 3. Dimensions of the system missing from site plan. (310 CMR 15.220(4)(e)) 4. Proposed contours missing and partial existing. (310 15.220(4)(g)) 5. Note listing all variances with proper citations missing. (310 CMR 15.220(4)(p)) 6. Tank less than 5 feet from porch and SAS less than 10 feet from porch. (NA 5.02) 7. No manhole stipulated on tank. (310 CMR 15.228(2)) 8. Note that tank must be watertight missing. (310 CMR 15.221(1)) 9. Tank loading not specified. (310 CMR 15.226(3)) 10. D -box not specified to be watertight. (310 CMR 15.221(1)) 11. Trenches to be used whenever possible. (310 CMR 15240(6)) 12. Vent not protected from animal entry. (310 CMR 15.241(1)(b)) If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, ._ -- Sandra Starr -,+M. Health Administrator Cc: R. Lamattina File CONSERVATION - (978) 688 9530 • HEALTH - (978) 688-9540 • PLANNING - (978) 688-9535 *BUILDINGOFFICE - (978) 688-9545 • "ZONING BOARD OF APPEALS - (978) 688-9541 • "146 MAIN STREET CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS The following is a checklist that incorporates all Title 5 and local regulations for septic plans. Name of Applicant:_F r9i4,G',b Z /91, r1)1711,.Ilf Name of Designer. J , Uz;s 6 Plan Date: Revision Date: Date of Review: % 71Z Property Address: RG �� �t%/ 1 SCC F. Map: f 1 Lot: BOH Reviewer: vim'• IsTh Type of Plan (new or upgrade): UP6 Number of Bedrooms in Assessor's Records: gpd) Garbage Disposal Allowed: General Information: N.A. =North Andover Septic Regulations Other numbers refer to Title 5 OK Problem N/A Street number and map/lot - 220(4)(u) Maximum scale of 1 "=40' for plot plan - 220(4) Maximum scale of 1 "=20' for profile and component details - 220(4) Legal boundaries of the facility being served - 220(4)(a) ✓ Names of abutters from recent tax map - NA 8.02j Number of bedrooms, design calcs., - NA 8.021 Name & address of record owner & applicant - NA 8.02k Name & address of designer - NA 8.021 Holder and location of all easements - 220(4)(b) ,i Date plan drawn & any revision date - NA 8.02m All dwellings and buildings, existing and proposed - 220(4)(c) Location of all existing or proposed impervious areas - 220(4)(d) ✓ All distances on site plan — NA 8.03a -c r/ Elevation of proposed driveway - NA 8.02t Location and elevation of foundation drain - NA 8.02y Location and dimensions of the system incl. reserve (new const.) - 220(4)(e) Limits of excavation of leach area on site plan - NA 8.02z ,/ Locus plan - 220(4)(t) North arrow - 220(4)(g) Existing and proposed contours - 220(4)(g) rf Locations and logs of deep holes - 220(4)(h) Locations and logs of percolation tests - 220(4)(i) Date(s) of soil testing - 220(4)(h) & (i) L/ Existing grade elevation of each deep hole - 220(4)(h) Elevation of percolation tests — N.A. 8.02n Name of approving authority representative - 220(4)(h) & (i) Name of soil evaluator - 220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines, drains, and subsurface utilities - 220(4)(m) ✓ Observed and adjusted g.w. elevation in the vicinity of the system - 220(4)(n) vI Complete profile of the system to scale - 220(4)(0), NA 8.02c Cross section of leaching facility - NA 8.02w y Location of benchmark(s) within 50-75 feet of facility - 220(4)(q) Note listing all variance requests with proper citations - 220(4)(p) Local upgrade approval request form submitted - 403(1) Original R.S./P.E. stamp, signature & date - 220(1) & (2) On-site Soil and Groundwater Review OK Problem N/A Proper deep observation hole logs on plan - 220(4)(h) Soil evaluation forms submitted within 60 days of field work - 0 1 8(2) Proper percolation test log - 220(4)(i) .� Ample deep observation holes in primary disposal area (minimum 2) - 102(2) Ample deep observation holes in secondary disposal area (minimum 2) - 102(2) ✓ Ample pert testing (one in each disposal area, 3 in prim. > 2,000 gpd) - 104(4) Hole Identification Numbers: ground elevation el. 9 7 /%' acceptable soil el. Leach facility invert el. 7", 9� ground water el. refusal el. 88 Jo bottom of leach facility el. 9 thickness of acceptable soil sfc. supplies (w/in 400'), pub. wells (w/in 250'), pvt. wells (w/in 150@) - 220(4)( before & after soil R&R Location of watercourses, wetlands, wells, etc. w/in 150' of system - NA 8.02r separation to groundwater Wetland disclaimer - NA 8.02s V,' Land surveyor plan reference required (property line setbacks) - 220(3) soil class Plan contains designer's certification statement ,f Use approvals / standards checked for I/A system - DEP docs., L.-- Perc rate >30 MPI - not allowed for new, LUA for upgrade - 245(1)&('3) i/ Perc rate > 60 MPI - must use modified tight tank or 1/A technology - 2 l5(4) pump tank below e.w. table V Proposed system qualifies as "shared" system - 002 (definitions) 11 in fill Flow is over 2,000 gpd - No R.S. allowed - 220(1) Design flow was set in accordance with code - 203 Existing system location and note on proper abandonment - 600.3. 1 (f), 354 Leaching facility at least V above Base Flood elevation - NA 9.05 All piping Sch 40 minimum - NA 10.01 �G Basement floor minimum V above groundwater elevation - NA 5.04 On-site Soil and Groundwater Review OK Problem N/A Proper deep observation hole logs on plan - 220(4)(h) Soil evaluation forms submitted within 60 days of field work - 0 1 8(2) Proper percolation test log - 220(4)(i) .� Ample deep observation holes in primary disposal area (minimum 2) - 102(2) Ample deep observation holes in secondary disposal area (minimum 2) - 102(2) ✓ Ample pert testing (one in each disposal area, 3 in prim. > 2,000 gpd) - 104(4) Hole Identification Numbers: ground elevation el. 9 7 /%' acceptable soil el. Leach facility invert el. 7", 9� ground water el. refusal el. 88 Jo bottom of leach facility el. 9 thickness of acceptable soil before & after soil R&R separation to groundwater , 3� separation to refusal 1J soil class aZ Perc rate O h7 / loading rate -S septic tank below g.w. table /J0 (yes or no) pump tank below e.w. table V — (yes or no) 11 in fill — -255(l) Setback Distances (Given in feet) 15.21 1 OK Problem N/A/ ' ✓ Is the lot in the Lake Cochiewick Watershed? NA 6.00 & 5.02 Septic Tank Leach Facility / c� Property line 10 10 L/ Cellar wall 10 20 Inground pool 10 20 Slab foundation 10 10 9/ Deck, on footings, etc. 5 10 Waterline 10 10 Private drinking well 75 100 (/ Irrigation well 75 100 Wetlands 75 100 ✓/ Public well 400 400 y Wetlands bordering surface 150 150 water Supply or trib. (in Watershed) Trib. To Surface Water supply 325 325 Reservoirs 400 400 Tributaries to reservoirs 200 200 Drains (wat. supply/trib.) 50 100 Drains (intercept g.w.) 25 50 / Foundation drains 10 20 Drains (Other) 5 10 Drywells 20 25 Downhill slope 15' to 3:1 slope w/o barrier Building Sewer OK Problem N/A ,/ Grease trap required for certain uses (check 230 for details) Pipe diameter listed (4" minimum) - 222(l) ✓ Pipe schedule listed - 222(3) Pipe cast iron or Sch 40 PVC — NA 11.02 Watertight joints specified - 222(3) & (4) Pipe laid on compact, fin base - 222(5) Pipe laid on continuous grade in straight line - 222(7)@ Cleanouts precede all changes in alignment and grade - 222(8) t Cleanout provided every 100 feet - 222(8) Manhole at any 90 degree alignment change - 222(8) Invert elevation at building: 27 !ffi Invert elevation at septic tank: _9Z -AA... Length of run: Slope: (minimum of 0.01 - 0.02 desired) - 222(6) ✓ 10' offset to private well or suction line - 222(2) Septic Tank OK Problem N/A Tank is accessible - 228(3) L__ Tank can accommodate both primary & reserve — NA 9.04 v 200% of flow (required & provided given. 1500 min.) - 220(4)(f) & 223)(1)(a) 2-3" drop from inlet to outlet - 227(5) Minimum of 4' liquid depth - 223(2) .� 3" air space above teesibaffles (minimum) - 227(4) ./- 9"air space above flow line (minimum) - 227(4) ✓— Tees are not to be replaced by baffles - 227(1) Tees extend 6" above flow line - 227(1) fInlet tee extends 10" below flow line (minimum) - 227(6) Outlet tee extends 14" below flow line (more for deeper tanks) - 227(6) ✓ Gas baffle installed on outlet - 227(4) Access manhole cover above center of tank & each tee (except 2 compart) 228(2) 3-20" manholes - 228(2) 1 childproof, 24" riser/manhole to final grade if <1000gpd- 228(2) Inlet and outlet tees on center line - 227(1) L___ Soil compaction below tank specified (if soil is non-native) - 221(2) 6" of <=3/4"stone beneath tank specified - 221(2) & 22 8(1) �G If> 1,000 gpd AND not a single fam. dwell. must be 2 tks or 2 comp. - 223(1)(b) t/ If plan specifies disposal must be 2 tanks in series or 2 compart. tank - 223(1)(c) Buoyancy calcs. required if tank at or below water table - 221(8) r/ Tank is watertight - 221 (1) 1/ 9" of cover over tank (minimum) - 228(1) H- 10 loading (min.) - H-20 if traffic - 226(3) Top of tank <=36" below grade - 221(7) All pumping to tank (if applies) in accordance with - 229 Tank is set to keep old system in service during install if possible Tight Tank (Check here if not present: !� ) Distribution Box (Check here if not present: OK Problem N/A Inlet elevation: ✓ Outlet elevation: t� 0.17' drop from inlet to outlet (minimum) - 232(3)(b) 6" sump (minimum) - 232(3)(e) All outlets at same elevation - 232(3)(b) ✓ Outlet pipes laid level for first 2 ft. - 232(3)(c) Pipe Sch 40 - NA 10.01 ✓ Number of outlets: �0 Number of laterals: L/ Size of outlets: c/ Inlet baffle/tee min. 1" over outlet invert for all d -boxes - 232(3)(a), tai Soil compaction below distribution box specified (if soil is non-native) - 221(2) 1/ 6" of stone beneath distribution box specified - 221(2) Box is watertight - 221 (1) Top of box <=36" below grade - 221(7) Buoyancy calculations required if box is at or below water table - 221(8) Pump Chamber (Check here if not present: c/ OK Problem N/A Volume specified: 220(4)(r) Pump on elevation- 220(4)(r) Pump off elevation: 220(4)(r) Alarm on elevation: 220(4)(r) Number of cycles per day - 220(4)(r) (also 254(1)(d) if gravity from d -box) Minimum 2" delivery line to d -box if gravity - 254(1)( c) Pressure dosed l.f if flow >= 2,000 gpd - 254(1)(a) & 254(2)(a) Cycles per day is consistent with chamber volume - 23 1 Volume calculations include flowback volume - 2') 1(2) 24 hour storage capacity above pump on elevation - 231(2) Number of pumps: 2 if system serves >2 dwelling units - 231(6) Capacity of pump(s) - gpm @ ' TDH - 220(4)(r) Pump can pass 1 1/4 "solids (minimum) - 231(7) Pump controls specified - 220(4)(r) Alarm equipment specified - 231(2) Alarm is in building and powered on separate circuit from pump - 2') 1(9) Pump sequence correct (off -lead on -lag on-alan-n on) - 231(8) Pump performance curves included - 220(4)(r) Manual operating switch - NA 12.01 Check valve, bleeder hole - NA 12.01 1 childproof, 24"riser/manhole to final grade - 2'31(5), Soil compaction beneath pump chamber specified (if soil is non-native) - 221(2) 6"of <=3/4" stone beneath chmbr. specified - 221(2) & 228(1), Buoyancy calculations if chamber is at or below water table - 221(8)@ 9" of cover over chamber (minimum) - 228(1) H- 10 loading (min.) - H-20 if traffic - 226(')), Chamber is watertight - 221 (1) Top of chamber <=36" below grade - 221(7) Leaching Facility (general - complete for all designs) OK Problem N/A Leaching Trenches (Check here if not present: L_� ) OK Problem N/A Number of trenches: Minimum of 2 trenches - NA 9.01(2) Depth of trenches (max eff. 2'): -247(l) Width of trenches (2' min., 4' max.): - 251 (1)(b) Length of trenches (100' max.): - 25 1 (1)(a) Trenches are vented (when > 50') - 251 (11) Trenches follow contour lines - 251(2) Trench spacing 3 times effective width or depth - 251 (1)(d) In fill or reserve between trenches, 10' min. - NA 14.01& 14.03 Available leach area given (Min. 500 s.f) - NA 9.01(2) 50% larger if garbage disposal - 240(4) Trenches to be used whenever possible - 240(6) No vehicle access or imperv. area above l.f. unless unavoidable - 240(7) ✓ Vented if under impervious cover - 241 (1) Vented through same pipes as distribution system - 241 (1)(a) Vent protected from precipitation/animal entry - 241 (1)(b) JL Vent is placed beyond traffic or impervious area - 24 1 (1)(c) f All lines connected to vent if bed or trenches - 241(1)(d) L,/' 9" cover over peastone - 240(9) Reserve area provided (new construction) - 248(1) c/ Reserve 4' from primary leach area — NA 9.04 4' (5' if perc rate <=2 MPI) separation to g.w. - 212(a) & (b) 1Z4' (down to 2' with variance or I/A - upgrades only) of natural soil under I. f. LIZ GW separation is adjusted to highest existing grade if facility cuts into a hillside ✓ Pipe slope minimum of 0.005 - 251(9) Require 5' removal and replacement if in fill - 255(5) Top of leach facility <= 36" below grade - 221(7) ✓ Final grade over l.f. minimum 0.02 ft/ft -240(10) ✓' Surface & subsurface drainage away from l.f. - 240(1 1) & 245(5) 3/8"-5/8" orifices specified (gravity system) - 251(8) Minimum design flow 440 gpd without deed restriction — NA 13.01 ✓, 3:1 slope where grading required - 255(2) Toe of fill slope stops T from property line or swale installed - 255(2) Impermeable barrier if < 3:1 slope or < 15 feet to —3:1 slope - 255(2) ✓ Impermeable barrier/retaining wall poured concrete — NA 9.02 Retaining wall stamped by P.E. - 255(2)(b) f Top of retaining wall >= top of peastone elevation - 255(2)(0 � 10' offset from edge of leach facility to edge of ret. wall - 255(2)(g) Perc test(s) done in most restrictive layer - 104(2) Perc test 4' below leaching elevation — NA 7.06 Design flow listed and required/provided leach area given - 220(4)(f) Leach pipes SCH40 PVC — NA 10.01 Leach pipes minimum 4" diameter except for dosed system — NA 14.04 Leach lines capped, vented, or connected together - 251(9) t/ Pressure dosing guidance followed if pressure distribution - 254(2)(c ), Pressure dosing required over 2,000 gpd or with I/A remedial use - 231(1) Leaching Trenches (Check here if not present: L_� ) OK Problem N/A Number of trenches: Minimum of 2 trenches - NA 9.01(2) Depth of trenches (max eff. 2'): -247(l) Width of trenches (2' min., 4' max.): - 251 (1)(b) Length of trenches (100' max.): - 25 1 (1)(a) Trenches are vented (when > 50') - 251 (11) Trenches follow contour lines - 251(2) Trench spacing 3 times effective width or depth - 251 (1)(d) In fill or reserve between trenches, 10' min. - NA 14.01& 14.03 Available leach area given (Min. 500 s.f) - NA 9.01(2) Bottom = L x W x # = s.f. Sidewall = L x D x# x 2= s. f. Effective leach area given Loading factor: Effective area = total area s.f. x LTAR = g/day Effective area is >= design flow of facility being served 2"of 1/8"- 1/2" 2x washed peastone.- 247(2) Trench depth of 3/4" to 1 1/2" double washed stone - 247(1) Leaching Pits (Check here if not present: �_ ) OK Problem N/A # of pits/pit systems: (dosing chamber if >1, 231 (0) Dimensions of each pit or system: L W D Depth of pits (max eff. 2'): - 253(1)(a) Available leach area given Bottom = L x W x # of systems = s.f. Sidewall = L x D x # of systems = s.f. Total area = bottom + sidewall = s.f Effective leach area given Loading factor: Effective area = total area s.f. x LTAR = _;/day Effective area is >= design flow of facility being served Minimum of 2 pits at least 13'X16' — NA 9.01(3) Distribution for galleries/chmbrs. in trench config. - pipe every 20' - 253(6) Distribution for galleries/chmbrs. in bed config.-ea.pipe serves <= 40 s.f.-253(6) Spacing - 2 times the effective width or depth (the greater) - 253(1)(c) 2"of 1/8"- 1 /2" 2x washed peastone.- 247(2) 3/4" to 1 1/2" double washed stone - 247(1) Each pit has at least one 20" access cover. 24" CI to grade over 2,000 gpd -253(3) Surrounding aggregate thickness between 1' (min.) and 4' (max.) - 253(1)(b) Vents, if necessary, extend under covers of pit(s) - 241 (e) Leach Fields (Check here if not present.- OK resent: OK Problem N/A n� Number of fields: l (need dosing chamber if> 1, 231 (1)) Length (100' max.): 0_0 ' - 252 (2)(b) ✓ Width: q,,5' Total area: L J-0 x W 'Z"_7 4ro s. f. Minimum 900 square feet - NA 9.01(1) ✓ Distribution lines connected with solid pipe — NA 15.01 Effective leach area given_ 7 Loading factor: IIQ5 -S _ / �J Effective area =.total area J�O s.f x LTAR °�3 = --� �/dav L_7 Effective area is >= design flow of facility being served L,.- Minimum of two distribution lines - 252(2)(a) 6' line separation (max.) - 252(2)(d) v 4' maximum separation from edge of field to line - 252(2)(e) 10' minimum separation between adjacent leach fields - 252(2)(0 L'_ Between 6" and 12" of 3/4 - 1 1/2" stone beneath field - 252(2)(g) & 247(2) ✓ 2"of 1/8"-1/2" 2x washed peastone.- 247(2) Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director July 27, 1998 Steve D'Urso 22 Lilly Pond Road W. Boxford, MA 01921 Re: 20 Laconia Circle Dear Steve: 30 School Street North Andover, Massachusetts 01845 •o This is to confirm that on July 23, 1998 the North Andover Board of Health granted waivers to allow S.A.S. 5' to lot line (10') 15, 211 CMR; tank < 5' to porch and S.A.S. < 10' to porch, N.A. Regulations 5.02. Along with these variances, the plans have been approved. If you have any questions regarding this letter, please call the office. Yours truly, Sandra Starr, R. S. Health Administrator SS/gb BOARD OF APPEAIS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE /o� � FEE: �6 PERMIT ## DATE APPLICANT h/%%%�I/a/Mw4 RECEIVED (cs 1619 MAP 10('13 PARCEL ADDRESS LOT # STREET # ', J ENG. --D /Ut-S 6 STREET ENGINEER'S ADD.,; ag I -ILII -y �d , EZ)X,,J-o& PLAN DATE CONDITIONS OF APPROVAL REV. DATE APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: k)tWe5 No -re ago (40(p) 4. &X f,5T/ �� ' " r b',w bou MST 1141:55`06, !7,lI5 SEPTIC PLAN SUBMITTALS LOCATION: �iOG`eyLC NEW PLANS: YES REVISED PLANS: YES DATE: '�/S' c� DESIGN ENGINEER: S $60.00/Plan 525.00/Plan When the submission is all in place, route to the Health Secretary Town of North Andover, Massachusetts Form No. 2 pORT#1 BOARD OF HEALTH of,t`'e y,1h _. o � � w 9 •�7���°�"T�T-�- ' DESIGN APPROVAL FOR ,ssACHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant�l`C.f7A-/Z.D�%lA T % / /t/ Test No. Site Location o7 0 LA�Cd h C//2,C Reference Plans and Specs S. / �s a ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee 60 • — Site System Permit No. J No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD �yOF HEALTH 'IaW,41 OF 4 /k/00 yEz APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Oo Repair (X Upgrade ( ) Abandon ( ) - gComplete System ❑ Individual Components a 4AKRM /} a /Z Location Parcel # Lot # Installer's Name Address Telephone # AcNACID ZA&A4i z1J14 Owner's Name ZgCA) t /a /9: Address Type of Building: �Z� Dwelling — No. of Bedrooms Other — Type of Building No. of persons Other fixtures Telephone # Desi ner's Name 7, 2 Telephone # Lot Size `I Sq. feet Garbage Grinder (As Showers ( ), Cafeteria ( ) Design Flow (min - required) J� gpd Calculated design flow gpd Design flow providedgPd Plan: Date 6%79 h2 Number of sheets _� Revision Date Title te /c' Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator 0 Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Jct C - C'- 77Lt,9IV The undersigned gr es to in II a ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu ree not lace e s ten -.,in operation until a Certificate of Compliance has been i sued by the Board of Health. Signed Date u �� Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Description of Work: THE COMMONWEALTH OF MASSACHUSETTS FEE OARD OF HEALTH CERTIFICATE OF COMPLIANCE ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer Designer: Inspector The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. , dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date FORM 2 - DSCP FORM 1255 (REV 5/96) Board of Health DEP APPROVED FORM 5/96 H&W HOBBSB WARREN TM PUBLISHERS - BOSTON I� f No. THE COMMONWEALTH OF MASSACHUSETTS FEE _ BOARD OF HEALTH Ad o F D AI�O t4EZ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (* Rcpair (,j Upgrade ( ) Abandon ( ) - ®.`Complete System ❑ Individual Components z0 LPCPAh ate -IOL 8 Location Map/Parcel # Lot # Installers, Name Address Telephone # K�eNA�'1� lA rrzm- Owncr's Name C AM I A Cid Address Type of Building: Dwelling — No. of Bedrooms Other — Type of Building No. of persons _ Other fixtures Design Flow (min required) 1 gpd Calculated design flow Plan: Date 9 if Number of sheets _ I Description of Soil(s) Soil Evaluator Form No. DESCRIPTION OF The unc TITLE 5 and Signed -)� Inspections �V Name of OR ALTERATf �� i^^ Telephone # Uiil�� 7 35- 2 /5,�—�'`ejV �� Telephone # Lot Size Sq. feet Garbage Grinder (AES Showers ( ), Cafeteria ( ) gpd Design flow provided4�gpd Revision Date 0 Date of E toiri II a describ n4liXi ual Sewage Disposal System in accordance with the provisions of it lace tem' operation ndl a Certificate of Compliance has been i sued bey/the Board of Health. _ Date `i FORM 1 - APPLICATION FOR DSCP kVEP APPROVED FORM 5/96 No. �- THE COMMd NEALT OF MASSACHUSETTS FEE i WARD OF HEALTH CERTIFICATE Ok, COMPLIANCE Description of Work: ❑ IIndividual Component(s) ❑ Complete System The undersi he� v certif lft`the Se�go'Diisppo�-al ystem; structed ( ), Repaired y; Upg aded), Abandoned( ) rIt Y at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated . Approved Design Flow (gpd) Installer Designer: Inspector Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE '' DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date FORM 2 - DSCP FORM 1255 (REV 5/96) Board of Health DEP APPROVED FORM 5/96 (Si) &W HOBBS&WARREN rM PUBLISHERS - BOSTON Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH OA APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ADDRESS TELEPHONE Site Location A0 L/'tf0V/'q clxo—e'l Engineer/✓E -�) v --e6-6 NAME ADDRESS//ff TELEPHONE Test/Inspection Date and Time ,Mi y i. ���� �� Aly ,•y CHAT AN, A RD OF H LTH Fee w Test No. 214 11 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH ,ED \2R'Oo oEw ea``^`a* APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer N - AME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee S.S. Permit No. D.W.C. No. C.C. Date Test No, Plbg. Permit No. BOARD OF HEALTH. 30 SCHOOL STREET NORTH ANDOVER, MASS. 01845 -7 7 t' " TEL. 688-9540 -- a APPLICATION FOR SOIL TESTS DATE: LOCATIO 0 SOIL TESTS.- ZAca,ViA _ olleC-6E Assessor's map & parcel number: OWNER: X1,CY9e,> TEL. ADDRESS: Z-0 1,4cyoulA (0,/ecCc ENGINEER: ,SSD lC:� . TEL. NO.: 3 2 797Z— CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the m� deep holes and two percolation tests required for each disposal area. Fe of $75.00 er lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. BAY STATE CHOWDA COMPANY 101 Phoenix Avenue - Lowell, Ma. 01852 Phone: 978-970-1144 0 Fax: 978-970-0450 Web Site and E-mail: http://www.chowdahead.com Date: Y' A /1992 Company Attention: f54 " v�. From:�. Number of pages (including cover) ,I �"k- NN S �,t �,I.e �' ��^ � ��.�� �) y W \,,.i• \ ���—cel �`\ J CA 1 BAY STATE CHOWDA COMPANY Cc aj- FORM 11 -SOIL EVALUATOR FORM Page 1 of 3 No. Date: Commonwealth of Massachusetts A© 4 A) D , Massachusetts Soil Suitability Assessment for On-site Sewage i nosal Performed By: S ,S C) Date: Witnessed By: Address or 4:,T- Z,460/)//4 /0 6 3 2 Owner's Name E7/ c /-0w a C) i , f 4 I—ri" Address and 2i) LAW4/A Cie Telephone # 02;E- 9-70 lmq New Constf fiction H Repair Yl Office Review Published Soil Survey Available: No F-1 Yes Year Published Publication Scale Y_l6( 7 Soil Map Unit (�4Afj-aAJ Drainage Class W Soil Limitations Surficial Geologic Report Available: No E21 Yes a Year Published Publication Scale A_ Geologic Material (Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year flood boundary No X Yes Within 100 year flood boundary No Yes Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range: Above Normal Normal Below Normal Other References Reviewed: DFP APPROVED FORM - 17/07/95 0 soikvwmm FORM 11 - SOIL EVALUATOR FORM �- Page 2 of 3 Location Address or Lot No. :P10 l—HCO�cJ� Deep Hole Number Date e Time 0100 Weather &; %2 Location (identify on site plan)�A3- -� �% /V Land Use %� �jr/ /� Slope (%) 14 Surface Stones Vegetation Landform . O,e/q-/ E Position on landscape (sketch on the back) Distances from: Open Water Body 9j�q , feet Possible Wet Area. f feet Drinking Water Well l --feet 11 Drainage way 90 feet Property Line �� feet Other DEEP OBSERVATION HOLE LOG* Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) lvy2�-- rs L 7,-q 6f—Z/ F5 •MIMMUM OF Z HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) T �_ Depth to Bedrock: Depth to Groundwater. Standing Water in nth---e��Hole: ���Z-:—' Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM -17/07/95 w;kvdym f - Location Address orLot No.. �p �IC©O'U 4 Depth observed standing in observation hole FORM 11 - SOIL. EVALUATOR FORM Page 3 of 3' C2` "'-� � inches Depth weeping from side of -observation hole inches Depth_to soil mottles 9�?)' inches. Ground water adjustment feet Index_VVell.Number Reading Date ' Index well level Adjustment. factor Adjusted ground water level Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,. what is the depth of naturally occuring pervious material? I certify that. on `% (date) I have: passed the. soil evaluator examination. approved by the Department of Environmental Protection and thatthe above analysis was performed by me consistent with the required training, expertise and- experience ndexperience described in 310 CMR 15.01 T. Signature Date G DFP APPROVED FORM - W07M soilevd.um Location Address or Lot No FORM 12 - PERCOLATION TEST Zo 1,4e_96x)1,ej- Oe COMMONWEALTH OF MASSACHUSETTS /� All) /�> , Massachusetts Percolation Test* Date: Z/ Time: Observation Hole# / Depth of Perc h Start Pre-soak End Pre-soak Time at 12" A01 Time at 9" Idz C - Time at 6" /I I S-Z) Time (9"-6") Rate Min./Inch *Minimum of 1 percolation test must be performed in both the primary area AND reserve area. w - Site Passed5i] Site FailedF] Performed By: Witnessed By: Comments: DEP APPROVED FORM - 12/07/95 Peram4SAM DATE: LOCATION: ENGINEER.- BOH NGINEER: BOH WITNESS: PERCOLATION TEST # BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: _ �T � �� ��_ (At least 15 minutes long) TIME AT 12" G TIME AT 9" TIME AT 6" ( J OVERNIGHT SOAK TIME STARTED - NEXT DAY SOAK.- TIME OAK:TIME AT 12" TIME AT 9" TIME AT 6" rr (At least 1 minutes) KAREN H.P. NELSON Director BUILDING CONSERVATION HEALTH PLANNING OF NORTH, Town of NORTH ANDOVER 7ss,CHU5�S4 DIVISION OF PLANNING & COMMUNITY DEVELOPMENT Memorandum TO : North Andover Board of Health FROM : North Andover Conservation Commission DATE : February 1, 1994 RE : Lot 20A Laconia Circle 120 Main Street, 01845 (508) 682-6483 The Conservation Commission has become aware that the owner of Lot 20 Laconia Circle is seeking a variance to build a septic system within 57' of a wetland. We would like to express our opposition to granting such a variance. Such a decision by the Board of Health would set a dangerous precedent and render the Town's 100' setback meaningless. We also ask that you consider changing the local septic regulations to require the applicant to notify immediate abutters before granting any variances of this kind. you. We appreciate the opportunity to comment on this matter before BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 20 Laconia Circle - Richard Lamattina: TEL. 682-6483 Ext. 32 Mrs. Starr updated the Board on the present happenings at 20 Laconia Circle's deck addition. A copy of the certified letter dated June 14, 1993 was in the Board member's packet. Mrs. Starr stated that the deck is approximately 18 feet and is in the leaching field. Mrs. Starr stated that he is putting 2 or 3 concrete pile ons, about a foot in diameter. Mrs. Starr stated that when she spoke to the State, they said, "as long as it does not impede the water flow". Mr. Osgood stated that if it overflows, Mr. Lamattina has to fix it. Mrs. Starr stated that she told him that, and it states that in the certified letter she sent him on June 14, 1993. ^' SENDER: •Complete items 1 and/or 2 for additional services. I also wish to receive the • Complete items 3, and 4a & b. following services (for an extra m y • Print your name and address on the reverse of this form so that we can fee): m return this card to you. > • Attach this form to the front of the mailpiece, or on the back if space 1. ❑ Addressee's Address N m does not permit. r m • Write "Return Receipt Requested" on the mailpiece below the article number. fS r 2. 11 Restricted Delivery «+ • The Return Receipt will show to whom the article was delivered and the date V CC delivered. Consult postmaster for fee. m 3. Article Addressed to: 4a. Article Number cc m P 273 797 654 ° Mr. Richard Lamattina 4b. Service Type 0 c❑ Registered ❑ Insureo V 29 Laconia Circle on 0 North Andover, MA 01845 Certified El COD H LU ❑ Express Mail ❑ Return Receipt for z Merchandise c 7. Date of D livery_ »- Q — -0 A 0 U 4- �- I V - --�M z z Vi:T oZc 5. ignature a ee) 8. Addressee's Address (Only if requested Y and fee is paid) W t M 6. Signature (Agent) F' 3 0 y PS Form 3811, December 1991 tr U.S.G.P.C.:1992-307-530 DOMESTIC RETURN RECEIPT UNITED STATES POSTAL SERVICE Official Business PENALTY FOR PRIVATE USE TO AVOID PAYMENT OF POSTAGE, $300 Print your name, address and ZIP Code here N. AMW'IER 13CARD OF HEALTH 120 "A(N STREET N. ANDOVER, MA. NP5 GIANT GLASS CO3(?� o, N Ss -ui CA o V n � m m �� Q mN � A � 01 � m s Z mC�� V ,�(,J, c? z Ln m i UC. y l V lJ co O m � � 3 z � o _ Lb U.) N —1 C? S z V 0 O °D cc cc NCl 00 800-54-GIANT/800-54-44268 COO WEYMOUTH 617-331-3550 CANTON 617-575-1150 CHELSEA 617-889-4590 LAWRENCE 508-686-81082 P-273 797 654 Receipt for Certified Mail R No Insurance Coverage Provided S TED STATES Do not use for International Mail POSTAL SERVICE (See Reverse) Sent to Richard Lamattina Street and No. 20 Laconia Circle P.O., State and ZIP Code Postage 2.29 Certified Fee Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom & Date Delivered Return Receipt Showing to Whom, Date, and Addressee's Address TOTAL Postage $ & Fees 2.29 Postmark or Date sent 6/15/93 10 _ r a©@Ls L®mr' O8c ©g sd _c CD \ 45 \\\ ,x \ )22 } Gn UJ iE § �CC \} kk§ j CA CA -_ ) \ uj �-C_ \\ \\ \E E 2 C, - §ca \ - OM � ]z{ - )k §) ) \§ } E Po CA &� IC k�k }j X12' {> E - 2�)U § §� _ \E \� \ \i )L f \§ \\§ {\-W {§ \- -� ;�f \/ ;2G� §� a- - ��\k / 13 __2 �� "i{I� _� i2 C6 p/_,oto ,aa•�•O\ .•• 4"1 BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext. 32 Richard Lamattina 20 Laconia Circle North Andover, MA 01845 RE: Deck addition Dear Mr. Lamattina: June 14, 1993 Certified # 273 797 654 Per our discussion concerning the footings of your planned deck replacement being placed in the septic leaching area: I recommend that you 1) decrease the size of your deck to avoid your leaching area; or 2) move your leaching area to avoid the deck area. You have stated that you do not wish to choose either of these options. Since the leaching area is not currently failing and since the State DEP feels that the footings should be able to be placed in the leaching area as long as the flow of the water is not impeded, then the Board will allow construction to continue with the following conditions: 1) If there is any sign that the septic system is failing it must be repaired immediately. 2) The Health Agent will monitor the septic system periodically for potential failures. If you have any questions, please do not hesitate to call the office. Sincerely, Sandra Starr Health Agent cc: Bob Nicetta, Building Inspector Karen.Nelson, Director, Planning & Comm. Dev. File 1 Date JO- is -9-S Homecwner:�� Street Phone Nature of Servicf� Observations: Description of Work: Comments: Routine Em argency Address: Phone Good Condition � Full to Cover Baffles in Place Leachfield Runback 4/0 Excessive Solids pa Heavy Grease Ab Roots Na Other (Explain) 5 Water ahe(i 9epi:ic . System Sexvieincx Re :)rt Date:/2 Homeowner : �-��!�c _ Pump,:r Street Address: ._,' Address : Phone : �G=�_- 6 _ Phone l Nature of Service: Routine Emergen--y Observations: Good Condition Gr"� Full to Cover Baffles in Place Leachf field Runback Excessi,je Solids Heavy G:.*ease Roots Other (Explain) Description of Work: Comments: TO DATE . n TIME,, P P© H F MM k OF AREA CODE �/ !�� NO. /�^ N EXT. E M FAX # E M g A E M 0 G E SIGNE PHONED ❑ BACLL K RETURNED ❑ SWANTST EEYOUO ❑ WAS IN ❑ AGAIN ALL ❑ URGENT ❑ FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: (� ICYWLi ) c.4M 0-r-rJ4J.4 Phone q i,5-5-3 J LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street LAco,vz� C_,I/ c.Lis St. Number o23 ************************Official Use Only************************ REMMENDATIONS OF TOWN AGENTS: l Date Approved J Z( Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments %. 1-4- Date Approved F d Inspector -Health Date Rejected Date Approved Septic Inspector -Health Date Rejected Comments C/L" _/C_/ C/C Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date WILLIAM F 'WELD Governor ARGEO PAUL CELLUCCI Lt. Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 01108 6I7,492•5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FbRM PART A CERTIFICATION Property Address: A0 %/* CAAt;4 /t%>\i-e\ /A�N VC4)Ndress of Owner: Date of Inspection: (.f — i�— g'� tll dif(erenll Name.of Inspector: (,q. ),,�,r.� 14( �YG� I am a DEP a rove system inspect ursuanl to Section 15.340 of Title i (310 CMR 15.000) Company Name: fl, Mailing Address: 0 W6 g 44pz— w vG� Telephone Number: U TRUDY COXE Secreuuy DAVID 8 STRUIIS Commissioner CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reponed below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience ,n the proper funa,on and maintenance of on-site sewage disposal systems The system: Passes _ Cond,t,onalk Passes Needs Further Evaluation By the Local AnDroving Authority Fails p f'� Inspector's Signal Dale: The System Inspector shall submit a copv of this inspection re o to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer. if applicable. and the approving authorit)•. INSPECTION SUMMARY: AI SYSTEM PASSES: Check A, 8, C, or D: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. :OMMENTS: 1 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. ;dicate yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If 'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance lattached) Indicating that the tank was installed within twenty (201 years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. -iced 0//75/971 Page 1 of 10 E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Dale of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed Pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with appro•:a] of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipets) are replaced obstruction is removed Cl 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 DETER/NINES THAT THE SYSTEM IS NOT FUNCTIONING IN A M.ANNER 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 (SIS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'v well. _ The system has a septic lank 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 and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (rrevisod 04/25/971 Paye 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address: a4:"' 1,A C 011 14 -DA— `44Ctl' , Abc; Vim. Owners -4 Al X417- 1A1,*Dale of Inspection: DI SYSTEM FAILS: iy tp YoU must indicate either "Yes- or "No" as to each of the following: I have determined that the system violates one or inore of the following failure criteria as defined in 310 CMR 15.303 The bans 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 invert due to an overloaded or clogged SAS or cesspool Liquid depth to cesspool is less than 6" below invert or available volume is less than 1/2 day flo%+ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). Number of times pumped _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Anv porton of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supple Any porton of a cesspool or privy is within a Zone I of a public well. -_ Any 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 wrth no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 0 LARGE SYSTEM FAILS: YoU must indicate either "Yes' or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 IN or greater (Large System) and the system is a significant threat to Public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet -of a surface drinking water supply 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 - IWPAI or a mapped Zone II 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 -equirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. revised 04/73/171 page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA1 PART B CHECKLIST Property Address: 02.0 1,C—I*A) /14 DN Owner: Dale of Inspection: kA s 1 N `f-- 3 . S� Check if the following have been done: Yod must indicate either "Yes" or "No- as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or / as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The iacifily or dwelling was inspected for signs of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. _ All system components. excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees. material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The faciltry owner tand occupants, if different from owner were provided with information on the proper maintenance of / Sub -Surface Disposal System. Existin¢ information. Ex. Plan at B.O.H. Determined in the field ttf anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 11 i.301(3)(b)l 0 Isiii•ieed 04/25/971 Page 4 of to properly Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORns PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design flow- g.p.d./bedroom for S.A.S Number of bedrooms: Number of current residents: Garbage grirdet lyes or no): Laundry connected to system yes or nol: Seasonal use tyes or moi:,,?V Water meter readings. if available (last two (11 year usage tgpd): Sump Pump Ives or nol:.Lib Last date of occupancy:Su_.V "4 COMMERCIAUINDUSTRIAL: Type of establishment: Design flow;_allonsrdav Grease trap present: Ives or not Industrial Waste Holding Tank present: (yes or not_ tion -sanitary waste discharged to the Title i system: tees or no)_ Water meter readings, ii available Last date of oCcupancy. OTHER: (Describe) Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and source of in System piped as part'of inspection: lyes or not_ If yes, volume pumped: ttallons Reason for pumping TYPE OF SYSTEM _ Septic lank/distribution box/soil absorptinn system Single cesspool Overflow cesspool Privy _ .)6 Shared system lyes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contractl Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) travised 01/2s/97i page 3 of 10 Properiy Address: Owner: ball of Inspection: BUILDING SEWER: (locale on site plan) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Ab .lav CwI A 4, 4di•v'+ V- 3 �- Orly �116h ?e -H ;) 0 v t.,_ Depth below grade: Material of construction: _ cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction ItnE Diameter Comments: (condilion of joints, venting, evidence of leakage, etc.) SEPTIC TANK:, (locale on site plant Depth below grade- 02 Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explainl If tank is metal, list age _ Is age confirmed by Cenificate of Compliance _ (Yes/No) Dimensions- kxl) Sludge depth--_ r/ Dislance from top ois 7 sludge to bottom of outlet tee or baifle: Scum thickness- A_ 01 Distance from lop of scum to lop of outlet lee or baffle- 16r, Distance from bottom of scum to bonom of outlet tee or baHle:- How dimensions were determined: Comments: (recommendation for pumping, condition of inlet a d outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ,(I Ti�Cfi — GREASE TRAP:_ (locale on site plant 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: Distinct! 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.) (revised 04/3S/971 ?age 9 of 10 t I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properi y Address: c;LO A. R CON.,,A iu d Ow net: A4,01 ,01 Dille of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locale on site plan) Deblh below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacih'. Eallonc Design flow gallons/da% Alarm level Alarm in working order _ Yes; _ No Dale of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. e(c.) DISTRIBUTION BOXX, (locate on site plani Depth of liquid level above outlet invert: Comments: Inote iflevel and_distrjbution is equal. evidenge of sol PUMP CHAMBER:_ (locate on site plant of,leakage int?pr out of Pox, etc.) ` Pumps in working order: (Yes or Not Alarms In working order (Yes or Nol Comments: (no(e condition of pump chamber, condition of pumps and appurtenances, etc.) I--_i__A .11 td. I... *­ 7 sI t0 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) properly Address: aq& kA C &V ii4 Owner: bale of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locale on site plan, if possible: ex ava(ton not required. /tram. but may be approximated by non -intrusive methods) If not determined to be present, explain: r - Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number- leaching umberleaching trenches, number.length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note fpndi ion of,vegetation, etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -lop of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool - Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY.- (locate RIVY:(locate on site plan) Materials of construction: Depth of solids: Comments: Incite condition oUsoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised WIS/171 tate / of 10 Dimensions: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: cZ 0 A C0A)1A- Owner: / ` � l Al Date of Inspection: h `/ �- 3 -5�r 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) • 4/25/s,) k * CO /�o 1,4 "d (I. ....6A7r — C.N"D F.q. 9 of 10 c i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSrECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 16— 3 Q Depth to Groundwater/6 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 from local conditions Check with local"Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words ho%v you established the High Groundwater Elevation. (Must be completed) �- 8 [,�t,✓t Jit' 2.J9'//J e-j2t�� .L� t �V AAroofnl o �c.r � �0 i 144. (revised 04/25/971 Page 10 of 10 0 r 11Vrt6x 1 • pLo-r' PLa�t • �Fo4z, MORTGAGE PURPOSES --BANK OSE ONL�� AD D a2.E S► S lo_ 20 L 4 c"0 t`f (At MORTGAGOR :_ V-tcj4aP.v !Er tilvATT(QA. r t � •'9• .:. .,,: . • ..;. ����'. .: .' Vie" .• �-•• ;�;; •'! ref ` a DQ 1 �./ W A`� G, .,/ ".v. �►' / rl' ,. EN CiZOAC W E a 6 Mfr, .. .:. .,,: . • ..;. ,t, , ..fli i--z-�., � •J. t (TA4 44�A4�, n;►4 FYA 9 r 'SCALE : I4o' owmea(s): R,EC* I STRY.. PLAN ,Wo -re upon pub<<c record s .tend av i/a,b/e phy�'lca� eYid�nce a,7, ; � ncC is l a54n )r7dic-a-61- o in om�vl ranee. . VATE :05( � • G E 2_'t F• t cNTF. • .Z' ce97'/FY -A v► Tie Lo 4 sno twn hereon 1`Jc�T 7I /-- - . 1. L l I� Cs S. 17c v/0 heY. ao n� , �i ha VI -7e 1'N��7'f'7/ rl c7 desl� ruc �e+c ,`` H of Flo t� (a �/'' Are =-L . =o'�� ROBERT �cyc (i1llETT GOODWINN 'A'o�t�E:R�' C, �oC7r.7ti�lltit,R,1..s. �►�, a 82 CE►4TRAt_ 1STMEE`r 4�o S�R� ��♦ ,Q. tt Doi/ FZ , O $ t O x MOO .- Olmoll AzI 0