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HomeMy WebLinkAboutMiscellaneous - 20 OLYMPIC LANE 4/30/2018juotin Jerome ;!r 01N,p � c bane Andover, MA, 01845 ;976)-666-8252 x Type: Em Cesspool: No Date of Pumping: System Pumped By: Contents Transferred to: Contents Disposed at: Commonwealth of Massachusetts Massachusetts System Pumping Record Routine Yes Wind River Environmental, LLC Date: ✓ l Pumper Signature: Condition of System/Other Comments System Location Pr..Lmary Home 20 Olympic Lane nrrn-4 "I"rnn Form 4 -- System Pumping Record y,' AUG G TONIN OF ^!CZ =R North Andover, MA, 01845 (978)-685•-8252 x Jumtin Jerome ® Printed on recycled paper Dep Approved Form - 12/07/95 Septic Tank: No Yes EX Quantity Pumped:_ Gallons Permit #: r-40 ✓Le-- kNVL, FORM U - LOT RELEASE FORM S' Su IU to/ ('I( oY 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 or requirements. 7*********************** "APPLICANT FILLS OUT THIS SECTION*********************** APPLICANTPHONE LOCATION: Assessor's Map Number. �' J PARCEL OR SUBDIVISION LOT (S) STREET CO 1 b:1 10< < AU `-- ST. NUMBER c ->D, CJ CO TOWN PLANNER COMMENTS OF OFFICIAL USE ONLY ENTS: TOR DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED FOOD INISIPECTOR-NE41 TH DATE APPROVED DATE REJECTED ,. PTIC INSPECTOWHEALTW DATE APPROVED DATE REJECTED �/ COMMENTSimy/vT� PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 Jm r FORM U - LOT RELEASE FORM <w,uv� Y-- PIC, C 1e, 60 Sv N u toI('I(oy 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 or requirements. I *****APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET O L -1 AL2 to, C ST. NUMBER o") (J OFFICIAL USE ONLY OF YQWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS .CIC X10 V o TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS AIV v �y-� �r� c- ,- .�. ! c7�L PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT 3 41--7 ix 1"-%-L v -, FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T6isr set" fei o file BUE DING PERNIIT NUMBER: DATE ISSUED: SIGNATURE: Building CommissionedIns for of Buildings Date SECTION t- SITE INFORMATION 1.1 Property Address: to/ 1.2 Assessors Map and Parcel Number: NO 0 Map Number Parcel Number ,o/c 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: LA Areas Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1 1.7 Water Supply M.G.L.C.40. 34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: ❑ private❑ Zone Outside Flood Tune ❑ Municipal ❑ On Site Disposal System ❑ PublicSECTION 2 - PROPERTY OWNERSIIIP/Al ORIZED AGENT 2.1 Owner of Record Name (Print)' Address for Se ice Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: ?U L4 ti � S � G4 w, �t,�.� Address Signature Telephone Not Applicable ❑ License Number 9 - OZ, Expiration Date 3.2 Registered Home Improvement Contractor Company Name ,� IN SC� Address Not Applicable ❑ Registration Number Expiration Date Signature _ Telephone OU C a m r SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building unit. Signed affidavit Attached Yes .......0 No ....... ❑ SECTION 5 Description of Proposed Work check a0 appReable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 9 -- Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: leg O x iv be - 1 W..CTiON A - RCTiMATFiI !'l1NCTDiir7inw nnomo Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by pennit applicant • 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (+) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number CV..rT11nN7onWVV1D A1rVV=n1DT AT7/A n n. -- —I l+L VV 11011% OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this builduig permit application. Signature of Owner Date SECTION 7b OWNER/AUWORIZED AGENT DECLARATION property ,as Owner/Authorized Agent of subject Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief ame� re of Owner/Agent _ _ Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIDERS 1' -)• 3 SPAN DIMENSIONS OF SILLS DIIviENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION • THICKNESS SIZE OF FOOTING X — MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS - System Pumping Record Form 4 All 1 Po �N fttjtw Ek DEP has provided this form for use by local Boards of Health. The S s e t lyrd m st be submitted to the local Board of Health or other approving authorit . A. Facility Information JUL 0 8 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ietmn 1. System Location: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT k 0.114 0-10 s Address AIA ore s City/Town State Zip Code 2. System Owner: _ 1--, 4-i,. I e—f Name — — Address (if different from Io*tioH) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): . 0(@C(5 - State Zip Code _ 57 8 - 6 66 -U6Q, Telephone Number 1$-05 Date 2• Quantity Pumped Cesspool(s) [Septic Tank 4. Effluent Tee Filter present? ❑ Yes E?--N'o 5. Condition of System: 6i brl 6. System Pumped By: _ 1660 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No /41 98617 NameFF II Vehicle License Number `j Company 7. Location where contents were ,di ipswlcHi` Wer rea — -- Signature of Hauler IHI.JVV 1%01 1, Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 RECE EVA D Commonwealth of Massachusetts L PR 04 2013 City/Town of OF NORTH ANDOVER _ system Pumping Record NORTH ANDOVTHDEPgRTMENT Form 4 h DEP has provided this form fq,r 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms onthe computer, use t __.. p( �./ y - - PC,- only the tab key to move Address your cursor - do not use the return CitylTown key.. 2 System Owner: -- ---- -� ego rm � ... -�-'►a � i r� Name ----- —— — Address (if diKeeeni from Location) City/Town -- --- ___ B. Pumping Record --------------- ..PA -MA O State Zip Code State p Zip Code -Telephone Number t 1. Date of Pumping D�`- -3I ---- 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [/-,Septic.Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): — — - - -- - 4. Effluent Tee Filter present? ❑ Yes YNo If yes, was it cleaned? ❑ Yes R No 5. Condition of System: 6. System Pumped By: -- Jim - Name EmA Company 7. Location where contents were disposed: — - - -N6ft AndoveA MA. Date Date 5i a e of Ha ler Stigaaiure of Receiving Facility Vehicle 1icense Number t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form 4 h 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 within 14 days from the pumping date*71 in accordance with 310 CMR 15.351. ��� Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. Facility Information 1. System Location: Address City/Town 2. System Owner: Name AddressAddress (if different City/Town JUN - 4 `'1011 — - TOWN OF NORTH ANDOVER I HEALTH DEPARTMENT _. State Zip Code Zip Code Te ephone Number B. Pumping Record — 2. Quantity Pumped. 1. Date of Pumping pate p Gallons 3. Type of system: ❑ Cesspool(s) U✓ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - -_ -- -- —.. - ------ 4. ---- 4. Effluent Tee Filter present? ❑ Yes [/N'o If yes, was it cleaned? ❑ Yes Eli/No 5. Condition of System: 6. System Pumped By: Vehicle License Number Nam Company 7. 7. Location where contents were disposed: -- �- Treatment Plant Signature of Hauler �`JSWIif�'hr 019J Signature of Receiving Facility _ Date 15form4.doc• 03106 System Pumping Record • Page t of 1 RRIER )EPTIC & DRAIN SERVICE OREST STREET; MIDDLETON, MA 01949 (978) 774-2772 "�1JA f FORM 4j S 'TEM PUMPING RECORD --'&COMMONWEALTH OF MASSACHUSETTS ' -e r , MASSACHUSETTS SYSTEM PT T ALPING RECORD ✓ + ✓ 11..i1Y1 �/ YY iVLSi(. utS 1r? P E61 SYSTEM LOCATION:' - J'^ 3' o�� o� Dunder )ATE OF PUMPING: /CO- /off - 7c/ QUANTITY PUMPED:_ 2,,$'7070 GALLONS -'ESSPOOL: NO 0 YES 0 SEPTIC TANK: NO 0 YES .YSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE 'ONTENTS TRANSFERRED TO: INSPECTOR:��r j� Commonwealth of Massachusetts Massachusetts System Pumping Record Form 4 -- System Pumping Record :ECriVED JUN - 5 2007 System Owner System Location TOWN OF NORTH AND9V' }iEALTH D1=PARTE i I: y,Rl�ii' _nif if• �:� lli yrrit��r i. �fl• 1 r i� ISI ' i r iji lA, U i 'i G j t R ^l lr l t,t { !'i - Ili �� �/.� 5i {�• JF'. I —i1H fl il,1 f" •�l! C 1 �k Type: Emergenc Routine Cesspool: No Yes Date of Pumping: _5 —l0 -D �– System Pumped By: Wind River Environmental, LLC Contents Transferred to: Contents Disposed at: Date: Condition of System/Other Comments Pumper Signature: Septic Tank: No = Ye4��D Quantity Pumped: /-5Z?Q Gallons Permit #: Dep Approved Form - 12/07/95 Type: Emergency Cesspool: w Date of Pumping: System Pumped By: Contents transferred to: Contents Disposed at: Daft Commonwealth of Massa : Massachusetts Location Routine Yes Wind River Enwmnnnental, LLC of System/0ther Comments Pumper Signature: V Dep Approved Form - 12/07/95 Form 4 -- system Pumping Record AJ RECEiVL..r) MAY 16 2005 TOWN OF NORTH A!`. 3 HEALTH DEPARTMENT Septic tank: No F7Yes F Quantity Pumped: 7 W,6 Gallons Permit #: NEW ENGLAND ENGINEERING SERVICES INC January 16, 1996 North Andover Board of Health Town Hall Annex 148 Main Street North Andover, MA 01845 RE: TITLE V REPORT I fvwM or -; MAN 2 2 1997 Enclosed is the Title V report for 20 Olympic Lane, North Andover, MA. The system passed the inspection. If there are any questions please call me at my office, 686-1768. Yours truly, Benjamin C. Osgood Jr. President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER,. MA 01845 - (508) 686-1768 . f William F. Weld Governor AM" Paul Cslluccl LL Gavomor Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Trudy Coxe S—etary flavld B. Struhs r-nmlatoner Property Address: Zi, 01 , � � � Len N c N • (} Date of Inspection: �' v M A Address of Owner - Name - Name of Ins il_? (If different) Benjamin C. Osgood Jr. Company Name, Address and Telephone Number. New England Engineering Services, Inc. 33 Walker Road, North Andover Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 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 ex maintenance of on-site sewage disposal systems. The system: perience in the proper function and Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date.- The ate: e System Inspector shall submit a copy of .this inspection report to the Approving Authority within t inspection- If the system is a shared system or has a design flow of 10,000 thirty (3U) Sys of completing this report to the appropriate regional office of the De SPd °r greater, the inspector and the system owner shall submit the The original should be sent to the Department se Environmental Protection. system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AJ SYSTEM PASSES. _ZI have not found any information which indicates that t Any failure criteria not evaluated are indicated below. he system violates any of the failure criteria as defined in 310 CMR 15.303. BI SYSTEM CONDITIONALLY PASSES: One or more system components inspection. need to be rept; or rep'd* Theme upon completion of the replacement or repair, passes Indicate yes, no, or not determined (Y, N, or ND)_ Descri imminent. The system be basis of determination is all instances. If "nal determined",explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, .or tank failure is will pass inspection if the existing septic tank is replaced with a . nforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500 A ie? Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2 0 o_) n. t 'c L -c, c Owner. J c H nj Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distrilxrtion 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): 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 pipe(s) are replaced 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 leis than 5 ppm. 3) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2 O r.. Owner. .TOL, Date of Inspection: 91ci2OL, D] SYSTEM FAILS: '1319 ? 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. 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 in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. 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. El LARGE SYSTEM FAILS: 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 gpd or greater (Large System) and the system is a significant threat toblic health and safety and the environment because one or more of the following conditions exist: pu 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 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 local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addrem 2,::, Ci 1,:) yv. tJ: c r` N C U. vT� S/J �t.� M t Owner. LJ o t' „ Date of Inspection: g'J Check if the following have been done: -"" Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A The 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. V'All system components, excluding the Soil Absorption System, have been located on the site. ZThe 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 bas been determined based on existing information or approximated by non -intrusive methods. ✓The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address 2,,� Owner. JGl„— Date of Inspection: G. RESIDENTIAI, Design flow: gallons Number of bedrooms: Number of current residents: Z Garbage grinder (yes or no): 2-0 Laundry connected to system (yes or no): -4A-5 Seasonal use (yes or no) AW Water meter readings, if available:__ Last date of occupancy:a ti. AZ -,,&t, FLOW CONDITIONS COMMERCIAL/INDUSTRIAL Type of establishment: Design flow:­--gallons/day 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: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sourgR of information: System pumped as part of inspection: C -.?,Or no)_ If yes, volume pumped: j b O c� gallons Reason for pumper T_o .,vs ^e(+ 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 6 _, , � i- i ' 1..q 7 1 Sewage odors detected when arriving at the site: (yes or no) A—) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addrem 20 Cil-) V"l9; Owner. Owne" Jol..., g�J cQ Date of Inspection: it 31 ci-7 SEPTIC TANK:_ (locate on site plan) Depth below grader / Material of construction: ✓ concrete _metal _FRP _other(ezplain) Dimensions: /a o i) Sludge depth.-­/a.:d Distance from top of sludge to bottom of outlet tee or baffle:,_ Scum thickness: 6"' Distance from top of scum to top of outlet tee or baffle:% Distance from bottom of scum to bottom of outlet tee or baffle: /0" 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.) % fl AV A i i AJ D Co A✓ O i 7-7 D GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or bathes, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Zu Ol; c AJ, Owner. Date of Inspection: JJ�� gays TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP --other(explain) Dimensions: Capacity: gallons Design flow:- gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) 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.) Ac"(e /ti«�l k PUMP CHAMBER_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: s Owner. `` AJ, 4_C0, ,2 i A, Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may approximated be a roximateby non -intrusive methods) If not determined to be present, explain W= I—ching Pte, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions:_ overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer- Depth ayerDepth 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 on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address !1 Owner. v �� GlJ'��'i c �u A-V 4—Sic amu. Nt Date of Inspection: 1 ell SKETCH OF SEWAGE DISPOSAL SYSTEM; mclnde ties to at least two permanent references landmarks or benchmarks locate all wells within 100' CA a m ?I - I- A -C 31. � 1� � DEPTH TO GROUNDWATER Depth to groundwater feet method of determination or approximation: K ,1 J t y A (revised 11/03/95) 9 z D' i IjU��GJrn ±� Neto _ v n c ir1 I -4 � ► m O n i � Z cp 0 0 Zoe x J(z U Z' C) �� ��+ ° Z M r) LA �� Z F -I r lA m ! t, L4 co coo rn - m i - rn -i o ' !! '� I -� T.% C, rn �t �r LA m fn mD -<I D r t 0 X D z CA 1 _7 Z H m LA i 'n on �rn N L N L Z 0 G r (M Z: v m a 2 L ~ t 1. s I j �r r tO o m c LO, LO (A no _ M 0 d LA O _IrF, ^; x� ' Z t� r Z!7� � N 2p -rrD T J, qrn' R, A = i _7 Z H m LA i 'n on �rn N L N L Z 0 G r (M Z: v m a 2 L ~ t 1. s --,,V" -=1 1 E LE \/AT t ® N'3 'vY Pipe S2QT OF H5E ti V- P1Pa I NTQ 'A Ja/. �\L.P1 PE s2_uT OF T,ANI V PIPE . %-10 p �nX UV 21 Pa CUT CD.-f!�QX . A S . u I L -r L- SYST EM - ►�1 '�,�... L Seo. t_E , • _ � ; C'_ D,o,-r e- , 1+ � � `. ' _1 �� F RAMC G � EL -1 f -j as A S Sc�c l -T- � N CSS � �VZC -k ITEGT S �St aND�/�t2ST Nc�.L�N�O�I��Z V -1;'Y7 m In FIC z/ -WE -7 DoT 1 ©L -.,*Ir. C m In FIC z/ -WE -7 DoT 1 ©L -.,*Ir. .ROV `' J) -, ;.A ,, E A. . moi, �i9 FA IL 1 OK DISzPPPOVED DATE Distance T o : ✓�?/t� ���,�.�L� _ Dran i s � / Well 2 t.'ater Line Location �. No PVC Pipe Septic Tank Tees - Length & To Clean Out Covers Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box Cover & Box - No Cracks All Lines Flowing Equal Amounts PTo Back Flow �F. Leach --Field or Trench �/ Di.rrens=ions so 1g St one nepth Capped Ends Clean Double gashed Stone %. Leach Pits Dimensi s Stone epth Sp sh Pads es Cement Pipe to Pit - Both Sides Clean Double ;:cashed Saone I'3o Ga,';a.rve Disposal 9. Final _---gad rq Tnspection 10. Barras -:I= L ng Co,17ered System As - Built Suh.mitted Lot Location Di rill en s on_s of System L.oca l ion :i_ t h Regard to Perc T� s Elevations 'r'ater Table A-- tXCAVA PION OK ",C� DI SPO SAL SYSTEM CHECK LI STX o 7 - NORTH NORTH AiNDOVER BOARD OF HEALTH APi-r��OVED .-E PROVIDED DISAPPROVED DATE TIME REASON ' " `/ `, �/r! � \✓� � �/� l" " r -c : / ..t -,tel Title 5 Reg. 2.5 Fail OK The submitted plan must show as a minumum: (a) the lot to be served (area,dimensions,l,ot //,abutters) (Planning Board files) (b) location and log of deep observation holes -distance to ties (c) location and results of percolation tests -distance to ties d) design calculations & calculations showing required leaching area (e) location and dimensions sf system (including reserve area) f) existing and proposed contours bo g-) location of any wet areas within 100' of the sewage disposal system ordisclaimer (check wetlands mapping) (h) surface and subsurface drains within 100' of sewage disposal system or'disclaimer (i) location of any drainage easements within 100' of ._ sewage disposal system or disclaimer (planning board files) (j) known sources of water supply within 200' of sewage • disposal system or disclaimer (k) --location of any proposed well to serve the lot (100' from leaching facility) (1) ---location of water lines on property (10' from.leaching facilities) location of benchmark x�`.�- driveways rgarbage disposers p-)-p)- no PVC is to be used in construction (q) a profile of the system (elevations of basement, plumbe pipe septic tank, distribution box inlets and outle'-s, distribution field piping and any other elevations) (r.) maximum ground water elevation in area of sewage dispos system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans S tic Tanks Reg. 6 (a) Capacities - 150% of flow, water table, tees, depth of tees, access, pumping, bCleanout 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains „north Andover Subsarl-ace disposal sSsLem enecx 31st Iage 2 ,a 1 Re'g.10.2 Reg.10. 1+- Reg.11 .2 Reg. 11 .4 Reg.11 .1 Reg.11.11 Reg.151 Reg. 15:1 Reg. 15.4 Reg. 15.8 Reg. 3.7 Reg.14.1 Reg.14.3 Reg.14.4 14.5 - Re g,.I 4. 6 4.5.Reg..14.6 Reg. 14.7 Reg.14.10 Reg. 9.1 Reg. 9.6 istribution Boxes Slope greater than 0.08 b� Sump Leaching Pits Leaching pits are eferred where the installation �,s possible (a) Calcula 16s of leaching area (minimum 500 S.F.) (b Spac' ( c S c -e drainage 2% d r material .2'>¢” Pf,Sk -� F -�'e a or, e,lbo 0�- eachinla Fields / -a) NDGreater than 20 minutes/inch b) Area (minimum 900 S.F.) c Construction of field d' Surface drainage 2% e 20' from,cellar wall or inground swimming pool Leaching Trenches (a Calculation f leaching area (min. 500 S.F.) (b Spacing ft. min. 6 ft. with reserve between) (c Dimens' ns (d C struction (e tone (f Surface drainage 2% Downhill Slope. (a Slope /x = (to be shown) (b� y/ 150 = (to be shown) f Pum (a) Ap oval ( b and -by power SOTT, PROF) LE & PERCOLATION TET DATA F3o- d of Heal.t-North Andover, Nass Strec I,ot No. Subdivis_r ori �- _ -_- Ovmer _ - Inves ti.ga.tor`_- ----_ _ _ _ Observer '�•� 1 . Da t El_ev. 72 OInches 2 _-2 96 rim SOIL PROFILES 2. Date 3. Date 4. Date Elev. Elev. Elev. J�, -I- �0 108 101-_120 ?Tote: Top & subsoil depth; depths of other soil types; depth of refusal. PERCOLATION TESTS Date Date Date Date Pit Number 60 Sta-rt 72 8 96 SOIL PROFILES 2. Date 3. Date 4. Date Elev. Elev. Elev. J�, -I- �0 108 101-_120 ?Tote: Top & subsoil depth; depths of other soil types; depth of refusal. PERCOLATION TESTS Date Date Date Date Pit Number Sta-rt Saturation I)ro;, of 3"_.Ti.me ---- l ` T1 nc.-- 73 Ties to Test Pits 1. 3 +. 4. 5• depth of water table; Date SOI1 , PROFILE & PERCOLATION TE-) DnTA ,/Board of He lth--North Andover, M ss. Street_.._. . _ _ �. Lot No.— Sub ? -v is:ion__ _� __.--- Oviner _ -- Investi_ga-tor— �— Observer SOIL PROFILES 1. Date 2. Date E1ev. Elev. Inches 0 3. Date Elev. dote: Top & subsoil depth; depth of refusal. Pit Number Start Sa.tu:rai,ion S o aI�- Start D,.aP - of 3" -Ti -me i -me Drop _ - -- of 6" --Tune Ti i ris. 'I st 3" Drob Mins. nd - 3" Ii:_0Q- — Min.jIn.- _ - 4. Date Elev., T_i_es to Test Pits 1. 2. 3. 4. 5 - depths of other soil types; depth of water table; 1. PERCOLATION TESTS T) Ilat(,. T)A t- f- T)a f:P naf'P nafP :;opy to Public Works t SUBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON. x'77 Title 5 Reg. 2.5 4 I Reg. 6 The submitted plan must show as a minumum: -raj^ the lot to be served (area, dimensions, lot #,abutters) (Planning Board files) --(--b-)" location and log of deep observation holes -distance to ties __-G -location and results of percolation tests -distance to ties __447) --design calculations & calculations showing required leaching area --{' location and dimensions of system (including reserve t area) existing and proposed contours g location of any wet areas within 100' of the sewage disposal system or- disclaimer (check wetlands mapping) ---(-IT)- surface and subsurface drains within 100' of sewage disposal system or disclaimer --(-I') location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) known sources of water supply within 200' of sewage disposal system or disclaimer --(� location of any proposed well to serve the lot (100' from leaching facility) —() location of water lines on property (10' from leaching facilities) - location of benchmark driveways I -P garbage disposers no PVC is to be used in construction ��a profile of,the system (elevations of basement, plumbers` pipe septic tank, distribution box inlets and outlets, i distribution field piping and any other elevations) { (r) maximum ground water elevation in area of sewage disposal .system plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (� Capacities - 150% of flow, water table, tees, depth of tees, access, pumping, (b Cleanout c 10' from cellar wall or inground swimming pool d 25' from subsurface drains No th Andover Subsurface disposal system check list - Page 2 Reg.10.2 Reg.10.4 Reg.11 .2 Reg.11 .4 Reg.11 .1 C Reg.11 .11 Reg. 15.1 Reg. 15.1 Reg. 15.4 Reg. 15.8 Reg. 3.7 Reg.14.1 Reg.14.3 'Reg.14.4 It 14.5 Reg.14.6 Reg.14.7 Reg.14.1C ?ail JOKI Distribution Boxes a Slope greater -than 0.08 b Sump Leaching Pits Leaching pits are preferred where the installation is p Visible (a Calculations of leaching area (minimum 500 S.F.) (b Spacing (c Surface drainage 2% d) Cgver material Leaching Fields �JJ a` (a) NoGreater than 20 minutes/inch (b) Area (minimum 900 S.F.) (c) Construction of field d Surface drainage 2% (e 20' from -cellar wall or inground swimming pool Leaching Trenches (a Calculations of leaching area (min. 500 S.F.) Spacing (4 ft. min. 6 ft. with reserve between) Rb Dimensions (d Construction (e Stone (f) Surface drainage 2% 1 Slone a Slope y/x = be shownb� y/x X 150 = �to be shown Pump 0 Reg. 9.1 I ! I (a) Approval Reg. 9.6 I (b) Stand-by power Ir Feet 0 1 7 4 6 7 8 9 SOIL PROFILE & PERCOLATION TEST DATA Board of Health -North Andover, Mass. ' Street Cv,,-.f_ Lot No. r Subdivision Owner G L_ad*z ' Investigator Observer 1. Date -f-7 Elev. Inches 0 RKM :7 sm SOIL PROFILES 2. Date 3. Date 4. Date Elev. Elev. Elev. Ties to Test Pits 1 • , ' . 2. 3. 4. Note: Top & subsoil depth; depths of other soil types; depth of*water table; depth of refusal. PERCOLATION TESTS nate 7-(3-72 T1at-P naiP nate Pate Pit Number 1 2 3 4 5 Start Saturation Soak�Mins. tart Test -Time z.:._ . Drop of 3" -Time Drop of '-Time Mins. 1st 3" Drop Mins. 2nd 311 Drop Rate Min. In. r V-AC.E a s p of YSTEM L ESIGN LOT - --L QTLY/O tC LANE NoaTM ANIDOVER, MA. PQLFI&KEo F ow- OLYMPIC. w- OLYMPi4 CoMSTAVC-nont CORP, -47 BAIL E Y 2o.A b . A,N ovER , MA. �iZAi'JIL C.G�LINAS i�tvp ASSOC►i►.'t6.S E^1C.%t-4 W- 's AND AR�HITS-CT S NoR?H QrvDov�iz0��«� Pp�►� NORT4-� ANDO�/E� R�MA.OI$45 T. aT AuGtmT a,,(9 -7a DESIGN DATA j CALCULA-TIONS vSOIC OBSERVA-I•IONS BY WITNESS P14I"IPs jo PEsRCOLAT ION -TEST NO. 1 2 3 - 4 S CWT E- , TOP -ELEVATION oz 1 00 -- BOTTOM - ELEVA-7 ION QD SATURATION -M%KS. — WATER -TABLE -7-// 12"—►9" DRoP-MINS, 9" —•- 6" DFLOP -MINs.—_`- GRA vEL PERC SOIL KOFILE-DEEP PIT No.' I — 2 3 - - 4 S DATE 7113178- - TOP- ELEVATION -- -TOPSOIL PARENT So1L WATER -TABLE -7-// GRA vEL WATER TA LE ELEVATION Q91,570 BOTTOM ELEVATION BUILDINCz�(PE �� w6[i«LIC: - _ 150 GAL. JUMIT =_ ro©D GPD FLOW to eon GPD Flow x 1S07. = G=PD USE / b n e) GALS EPTIC -rAAK i LEAC"INcw AREA' BED G•PD FLOW x SF/G-AL.= SF 13 EZ USE SF TYP!? 4 MFR.(TYP.) :5 -NEA SH -AU -0W BITS LV/2'-C" _y7-06JPERIMETER S I DEWAALL AREA,; SF x 2.5 GAL %. j -SF = 215.75. GPD oSoTToM AREA : 11)9._..SF x_ 1 GAL.s.j SF = 109.'70 GPD TOTAL PIT LEACH INC -t CAPACITY _ _ _ _ _ _ _ _ 325, 15 GPD /PIT GP D FLOvN -s--132 45 GPDIPIT = /. B 4 PITS READ . USE 3 PITS Tit ew C H ES : SIDEWALL ARE F/ LF GALS '$r = GAL./L{N-FT. $OTT'OM A SF/LF X GALS/SF = GAL./ LIN.FT, -Tc7TAL NCH LEACH1NG CAPACITY _ _ _ _ _ GAL,/ UK -PT. PD PLoW _ SOL �LI1l.FT.= L.F.TR1r NCNES REQ'D. U SF-L.F No -r Et: Al 1 mo 00 Aj i - -�-- - L J Z ©* XOfl -a sI© --, a jV , , o a r `�1 O O W o z J -- S 'CD j J i d LL Q E -IC N Z t u Y Q F o o} N d a X 1" Q u a Z O LN 2Q �1�0 �►�t9 W ICD (ANIOL a3S0-1-:)) Mid 3�iS31�'1�43„� xNb+i ;ILLd73ls- .-too *p N ! 1 '13M(a 1PA%E 3 - QE -`f jV o a `�1 O o z 'CD d LL Q E -IC N Z *p N ! 1 '13M(a 1PA%E 3 - QE -`f �7 >8 �U HYuRANi SN'NpLE !N FRONT Off' LQT A, - `EGfN� - I rt3 ELEVATION = 105.S9 LAT/ON TEST /NJTA1.Lf0 {� —LS T T ._. t v S, A!P,-ACE JV 4 TEA" vTry (Ad =F .� ySTfM ,3 �? Sc, ^fE cyr' JuasuA pACt / 4•tis c.? CASCA46ivT3 -'�` `'�20nOSE� �.OJvTOUR 1 NrTYar/V �Mf 'T yr }Yy/E,t4 J LEAGNIN� PoT 4 To-' A&b JuBsolG sN^LcLOT — RESERVE AREA f?E.yoWerD ^r EEA.C#+ ArPEA AtjL p�1C 1, ... ` -� SE�^R_VICE aC 8 jWAT`esa, 1DP^I N AGE CATCK rlEcr.c+vs .+,,;LYMPI� v J dd , G veL AU&UST 81 X978 F� -5. LL DE41RED WL7LAND FlMI .��E