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HomeMy WebLinkAboutMiscellaneous - 200 RALEIGH TAVERN LANE 4/30/2018m t m 9 Y 4750 O� •MO eT� 1y .. Town of North Andover �'•�:, o :.`' HEALTH DEPART MENT CHECK #: J /TATE: LLOCATION: , H/O NAME:/ CONTRACTOR NAME: �'�C� ' 1� Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval- $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ /Titl5 Inspector $ Title 5 Report ?i ❑ Other. (Indicate) $ Health Agent Initials'; White - Applicant. :Yellow -Health Pink -Treasurer North Andover Board of Assessors Public Access gORT1l si •♦ CHU Click Seal To Return Summary Residence Detached Structure Condo Commercial North, Andover Page 1 of 1 roperty Record Card Location: 200 RALEIGH TAVERN LANE Owner Name: O'BRIEN, RAYMOND A & DEBRA A Owner Address: 200 RALEIGH TAVERN LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7 - 7 Land Area: 1.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2832 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 545,400 576,900 Building Value: 319,500 352,100 Land Value: 225,900 224,800 Market and Value: 225,900 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1519232&town=NandoverPubAcc 1/29/2010 DelleChiaie, Pamela From: Ben Osgood Jr. [bosgood@neengineeringinc.com] Sent: Thursday, January 28, 2010 6:55 PM To: DelleChiaie, Pamela Subject: 200 RALEIGH tAVERN LANE Hi Pam, I am doing a Title 5 inspection at 200 Raleigh Tavern lane of Saturday. Can you see if there is an as built or an old Title 5? If the old title 5 has a diagram that is all I would need. Thanks Ben Osgood Benjamin C. Osgood Jr. P.E. I Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ILEI Commonwealtfil of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleiah Tavem Lane Property Address G �� Ra O'brien Owner's Name North Andover City/Town MA 01845 1/30/10 State Zip Code Date of Inspection inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Benjamin C. Osgood, Jr. Name of Inspector none Company Name 16 Hillside Avenue, Unit 3 Company Address Amesbury Cityfrown 508-328-4633 Telephone Number B. Certification MA State 870 License Number 01913 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority f";" ('02 1/30/10 Insl:;dorsAignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Owner information is required for every page. Commonwealth" of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner's Name North Andover MA 01845 1/30/10 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner's Name North Andover MA 01845 1/30/10 CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is required for North Andover MA 01845 1/30/10 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavem Lane Property Address Ray O'brien Owner owner's Name information is required for North Andover MA 01845 1/30/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elev ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water suppl tributary to a surface water supply. E]® Any portion of a cesspool or privy is within a Zone 1 of a public well. E]® Any portion of a cesspool or privy is within 50 feet of a private water suppl El® Any portion of a cesspool or privy is less than 100 feet but greater than 50 from a private water supply well with no acceptable water quality analysis system passes if the well water analysis, performed at a DEP certifie laboratory, for fecal coliform bacteria indicates absent and the prese of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 p provided that no other failure criteria are triggered. A copy of the ana and chain of custody must be attached to this form.] 1:1® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E]® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. system owner should contact the Board of Health to determine what will b necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. or ation. y or y well. feet [This d nce pm, lysis The e For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner's Name North Andover Cityrrown C. Checklist RBA 01845 1/30/10 Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is North Andover MA 01845 1/30/10 required for every page Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavem Lane Property Address Ray O'brien Owner Owner's Name information is uired for North Andover MA 01845 1/30/10 req every page. Cityrrown State D. System Information (cont.) Last date of occupancy/use: Other (describe below): Zip Code General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Date of Inspection 11/26/07 Der boh records gallons ❑ Yes ® No ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavem Lane Property Address Ray O'brien Owner Owners Name information is uired for North Andover MA 01845 1/30/10 req every page. Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: Installed 1981 Der BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth belowrade: 15' g feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks OK in basement Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2.5 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallons Sludge depth: 2" Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavem Lane Property Address Ray O'brien Owner's Name North Andover MA 01845 1/30/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 33" 2" 6" 14" How were dimensions determined? Measure Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Sch 40 PVC Tees in good condition. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is required for North Andover MA 01845 1/30/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: gallons gallons per day ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is required for North Andover MA 01845 1/30/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box replaced at last inspection. Box in very good condition. Distribution equal. No evidence of leakage or solids carryover Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleiqh Tavern Lane Property Address Ray O'brien Owner Owners Name information is North Andover MA 01845 1/30/10 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 1 Field 25'X 45' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of leach field looks normal. No evidence of ponding, damp soil, or unusual vegetation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner's Name North Andover CityrFown MA 01845 1/30/10 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Owner Information is required for every page. Commonwealth of Massachus®tts Title 5 Official Inspection F sat>�suriacle age o� �e� s p orrn P ystem Form , Not for Voluntary Assessments 240 Raleigh Tavern lane rope tY Address --� ---- OwnsPS Name North Andover CitYlrown D. System Information (cont.) MA 01845 3/31/09 State Zip Clip Code Date of Inspection Sketch Of Sewage Disposal System: Provide a view of the sew at least two permanent reference landmarks or benchmarks, Locate Ball wejjg thin 140 fes eet. 0 to Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately pr WrA N[ cr. ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Site Exam: ® Property Address Ray O'brien Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 1/30/10 Date of Inspection Estimated depth to high ground water: 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: System located in an area that is raised 2 to 3 feet above surrounding grade. USGS Maps indicate water greater than 6 feet below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is required for North Andover MA 01845 1/30/10 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 8, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Commonwealth of Massachusetts u . City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 �,......._-- °r IVE.D DEP has provided this form for use by local Boards of Health. The�.System Pumping Recor 'must be submitted to the local Board of Health or other approving authority. DE 1 O 2007 A. Facility Information �_;,F. ;.�pRTH ANDOVER. ' Important: ?DEPARTMENT When filling out 1. Systema qh forms on the 4� D /pr• computer, use (L only the tab key Ad ress !n/ to move your 0/er'' ®/ FL16 cursor - do not Glty/Town State Zip Code use the return key. 2 Sy m Owner: Name Address (if different from location) City/Town State � � �— � Zip Cosie� Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 2. Quantity Pumped Date Cesspool(s) Septic Tank 4. Effluent Tee Filter present? ❑ Yes VNo 5. Condition of System: ZU ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 6. em Pumpgd By: � & me / Vehicle License Number ompan 7. Location where contents were disposed: Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect - /% 0--7- 0 Date t5form4.doc° 06/03 System Pumping Record ° Page 1 of 1 RECEIVES 'rowN OF N RTH ANDOVER 2004 SYSTEM P MPINQ RECORI) TOWN OF NORTH AN, - F L) A 11 W LT �OVER 4 NOVLHEALTH DEPARTM'E'NT SYSTEMF.R& ADDRESS A� x 0 0 y 0 1 hM LOCATION ol DATE OF PUMPING: CLSSPOOL: NO .-QUANTITY PUMPED: SjP(ic Tiuik: NO_ YES NA rUKE OF SERVICE: ROUTINE OM1 -- , bmERGENc). Q b s FR V A 1`10N 8: GOOD CONDITION PUI.l, 'ryi COVER ,HEAVY 0"-ASEBAFFLES IN PLACL ROOTS LEA-CKFlF-LD RUNBACK BXCUSIVE SOLIDS—_ FLOODED SOLID CARR YOVERI-....... OTHER EXPLAIN ...... SY*L*M Pwnpcd by �:UMMENTS. L:(')N I EN I'S I"KANSYbRUD I'o WN OF NORTH -AN -DOVER SYSTEM PUMPING RECORD /a 2 2003 1-s HM OWNER & ADDRESS „ SYSTEM LOCATION - R —T.�- 0�'Gt�/�/7 (MMpfe: Left front of house) U:\"I'C OF PUMAINC:„ —_o�_ QUANTITY 0 U M P C D 4c20 ' ►':»I'UUL:V NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE � EMERGENCY (�IhrRY:ITIONS: COOD CONDITION. ✓ FULL TO COYEk - Cil HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD IwNBACK... CXCESSIYE SOLIDS FLOODED SOLIDS CARRYOYER AHER (EXPLAJN) i1''I'L'Nf PUMPEii BY: ,!��1�'�'�'4�1`�:.' Y L u,1 `y1 2NTS; U.'•1*1-,. ,I'S !,RANSPCRRED TO: f ' DATE OF PUMPING c ;r QUANTITY PUMPED 15D70 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES s NATURE OF SERVICE: ROUTINE EMERGENCY O$SERVATIONS: ljz h . GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ROOTS LEACHFIELD RUNBACK f .. EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER _ OTHER (EXPLAIN) VI PUMPED BY: �c TRANSFERRED TO: SYSTEM OWNER &ADDRESS iDATE• -6 _ (example: left front of house) - aBr • r, -j,1 ' TOWN OF NORTH ANDOVER ' SYSTEM PUMPING RECORD f ' DATE OF PUMPING c ;r QUANTITY PUMPED 15D70 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES s NATURE OF SERVICE: ROUTINE EMERGENCY O$SERVATIONS: ljz h . GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ROOTS LEACHFIELD RUNBACK f .. EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER _ OTHER (EXPLAIN) VI PUMPED BY: �c TRANSFERRED TO: SYSTEM OWNER &ADDRESS iDATE• -6 _ (example: left front of house) - aBr • r, -j,1 c �, f ' DATE OF PUMPING c ;r QUANTITY PUMPED 15D70 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES s NATURE OF SERVICE: ROUTINE EMERGENCY O$SERVATIONS: ljz h . GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ROOTS LEACHFIELD RUNBACK f .. EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER _ OTHER (EXPLAIN) VI PUMPED BY: �c TRANSFERRED TO: SYSTEM OWNER &ADDRESS SYSTEM LOCATION. { _ (example: left front of house) bqJq S _ ' /+ e tc t 5�i,�V Y L'.�•i ¢XPi L � A 4 '. � 1 f£ JJ I �Jfkk 1!Ie�4s�1 pf rva �R , f IO�d r f ' DATE OF PUMPING c ;r QUANTITY PUMPED 15D70 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES s NATURE OF SERVICE: ROUTINE EMERGENCY O$SERVATIONS: ljz h . GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ROOTS LEACHFIELD RUNBACK f .. EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER _ OTHER (EXPLAIN) VI PUMPED BY: �c TRANSFERRED TO: To / co,J tr tt .4 11711 rr' y To / co,J HAUL LIC # 777 $100 1996 INST LIC # 659 $200 1996 NO ANDOVER BOH TOWN HALL ANNEX 120 MAIN STREET NO ANDOVER, MA 01845 PH# 508-682-6483 508-688-9540 ** FAX 508-688-9556 Dear SIRS: STEWWART'S SEPTIC TANK SERVICE 47 RAILROAD STREET BRADFORD, MA 01835 508-372-7471 May 3, 1996 The following is a list of properties that we pumped in your town. In accordance with TITLE V regulations, we are complying by sending you the following on a monthly basis, if need be. If we didn't pump, you will not be notified. PUMP DATE ADDRESS GALLONS 04-01-96 197 ABBOTT STREET 1,500 105 WINTERGREEN DRIVE 11000 04-02-96 A 42 OLYMPIC LANE 11000 04-04-96 A 71 PENNI LANE 11000 04-06-.96 492 SHARPNER'S POND ROAD 11000 A 39 HAYMEADOW ROAD 1,500 04-08-96 498 WINTER STREET 11000 187 SOUTH BRADFORD 11000 04-09-96 A 495 REA STREET 11000 04-10-96 A 706 FOSTER STREEET 11000 04-11-96 A 83 CAMPBELL ROAD 11000 04-11-96 A 43 CHRISTIAN LANE M 1,500 04-12-96 7 HAYMEADOW ROAD 11000 1577 SALEM STREET 11000 04-13-96 278 BARKER STREET 11000 04-16-96 A 30 BRENTWOOD CIRCLE 11000 04-17-96 A 27 COACHMAN'S LANE 11000 04-18-96 369 HIGH PLAIN ROAD 11000 28 CEDAR LANE 11000 A 121 CAMPBELL ROAD 11000 04-19-96 A 160 BRIDALPATH LAVE 2,200 04-20-96 A200 RALEIGH_ TAVERN LA114E 1,500 A 1 GARFIELD LANE 1,800 Zv HEAVY TO: NQeT" 4"Dc:.i&e g6& rt, C� 14 FROM: e>(--- L% 4-1 &'T NORTH ANDOVER, MASS. BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have inspected the onstruction materials of said disposal system at L_C)'T (-X--\ 6s Eg-*j Lam` Site Location North Andover, MA. The grades and construction materials are as specified i my plans and specifications dated 1 1 'Z-�-'t 19 80 and !� 19 (z) Reg. Prof. Engider/Reg. Sanitarian t.% COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2-o0 ea -1 KV o (,, m, a4 Owner's Name: Owner's Address: Date of Inspection: RD ---16 n j `� '/ Name of Inspector: (please print) L X�F1Y1.i,Jf V t f1C nzo Company Name: ,.?° i- " Mailing Address: "1 U( Telephone Number: q r1 A` 5 9 Z.- 9 q"i s iCiJtfsV OF +SCR Y H AG+a BOAR—OF 2001 r d CERTIFICATION STATEMENT I certify that.I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs er%Evaluation by the Local Approving Authority 1 / Fils � / Inspector's Signature: The system inspector shall Obinit a copy of this inspection report tffthe Approving Authority (Board of Health or DEP) within 30 days of co pleting 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. Title 5 Inspection Form 6/15/2000 page 1 -Page'2 Af 11 i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 77_00 cw Lts Owner: Date of Inspection: I to "-0 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes:. , I have not found any information which indicates that any of the failure criteria described in 310 CMR 1f`5:303 or in 310 CMR 15 304 exist. Any failure criteria not evaluated are indicated below. -,- B. System Conditionally Passes:­rl, f 1.1 , 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. 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. s 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 approvaVofBoard=.of Hearth)`: broken pipes) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed - ND explain: 2 Page 31 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2 Q 0 t"10f4ch Pcod4tie-y— Owner: Date of Inspection: 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 Ts failing to protect public health, ' safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in ,a manner which will protect ppbjic,health, safety and: theenvironment: 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 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and ,tbq,preseiice of ammonia nitrogen and nitratepitrogen isiequal to or lesi.than 5. ppm, provided that-no.oqler criteria : are triggered' A-'-c'o*p-'y of & anIlysis must lelaitach'ed tolWs form.'. 3. Other: 3 u z Page4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: O(� { A , 1r1 � n. LKi . Owner: _J S Date of Inspection:—LO— Ica -01 D. System Failure Criteria applicable to all systems: You must indicate "yes'.or "no." to each of the following for all inspections: ,Yes ..�. No l� V ,,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 logged SAS or cesspool -Stat c liquid level in the distribution�box abo a outlet invert due "to an overloaded or clogged SAS or /Cesspool ' Is �Liquid.depth in cesspool is less than 6" below invert or available volume is less than V2 day flow — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped : , _kny portion of the SAS; cesspool or privy is below high ground water elevation. Any portionof cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _'Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm, 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 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a lar a system the system must serve a, facility with 4 design flow of _1'0;000 gpd,to M 00 �. K" A. gpa�" f' n You must indicate either "yes" or "no" to"each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply _ - the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone I1 of a public water supply well 7 - If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. f',' 4 : Page7`s of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2-0 QM NoN." Owner:�.�%4 Date of Inspection: t O— t 6-01 Check if theifollowing have been done. You must indicate "yes" or "no" as to each of the following: 't Pumping information was provided by the owner, occupant, or Board of Health { -Were anyWthe systerrrtomp-onents pumped but inttie-previous'twa 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 ? i Were as built plans of the system obtained and examined? (If they were not available note as N/A) ✓_ Was the facility or dwelling inspected for signs of sewage back up ? V Was the site inspected for signs of break out ? y Were all system components, excluding the SAS, located on site ? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? l,%_ 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 Of . AllF• (/ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 . .. .... .. ...`.T .,r ... syq�4,•'i-wA+h:vM'a"a(a�W.^- ,i'r§e::9 .�:., yitie'.. }ti�'"�-..Vt.'e{+niY's Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2-00 &1 Owner: A c Date of Inspection: 0 — t o — FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on.310 CW 15.203 (for example: 110 gpd x # of bedrooms): ti Number of current residenis: �r .i Does residence have a garbage grinder (yes or no): /10 Is laundry on a separate sewage system (yes or no):/Voif yes separate inspection required] Laundry system inspected (yes or no) Seasonal ;use: es dr'6)&0 Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): 'Last date of occupancy 1 e COMMERCI1/1, L Type of establishment Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): 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: rnet (n � QO Was system pumped as part of thespection (yes or no): _ If yes, volume pumped: ga ons -- How was quantity pumped determined? Reason for pumping: TYPt,4 SYSTEM eptic tank, distribution box, soil absotptian systemy _ 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): Appro ; t a e,fall components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no):,At } q k. s 6 M A t Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Z01D&1ekihTw-om- tw4 Owner: BAAS Date of Inspection: BUILDING SEWER (locate on site plan) Depth,below grade - Materials of construction: cast iron 4/0 PVC —other (explain): "Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): -ki .SEPTIC TANK: A K* (locate on site plan) Dept below graL": Material of construction: e'oncrete —metal —fiberglass ___polyethylene ____other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: t,9 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of Scum to top of outlet tee or baffle: Distance from bottom of scum to botLtomx outlet tee or baffle: How were dimensions determined: 7 4 /tW- Comments (on pumping recommendationsVmlet and outlet tee or baffle condition, structural integrity, liquid levels as r8ted totlet in)�-Z, evidence of leakage, etc.): O+OK (p fi&o00l -5ZIap-a, GREASE TRAP: _(locate on site plan) Depth below grade: Material of construction: —concrete —metal —fiberglass __polyethylene —other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 ... � .. � .-., ,.:w.,„ ..,,.i,,-.,. r ,. "w.r� � . hre.a�h�•, a;*,.�.,�...;tawa*F�•ys:}g�Y�...rk+•y�5a�r.T'+1i�3'`ea.;. �.x Vie+•, .a . �r Kw-,, .,r,.. •- Page '8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .H SYSTEM INFORMATION (continued) Property Address: .2- 00 ' ,2 h �n Owner: Date of Inspection: TIGHT or HbLDING TANK: ` ' (tank must be pumped at time of in spection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): i Dimension ; a.t E:... . y 4, # "1' } Capacity Design Flow: gallons/day. . Alarm present (yes or no):.., level: , `Alarm in working order (yes or no): Date of last pumping K` Comments (condition, of_. alarm and float switches, etc.): DISTRIBUTION BOX: —k/<if must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover. anv evidence of PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): ' Alarms in working order (yes or no): Comments (note condition of pump chamber, con �n of pumps and appurter es, etc.); r a A f 8 es, etc.); r Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Z Uef'1), '! Owner: Date of Inspection:..�J SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why:` . ype leaching pits, number: _ leaching chambers, number: leaching gallenes, number: " ""ledching trenches, number length: r '" 1 ching fielits number, dirnensions: t overflow cesspool,,number innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): '06,A.) CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) M1 Number and configuration: Depth — top of liquid to inlet invert: t Depth of solids layer: Depth of scum layer: r Dimensions of cesspool: Materialsofconstruction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level_ of ponding, condition of vegetation, etc.): ;�y PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 i 4.. ... �r,..k, �,r.. w .. *; �„.�.� ,-,��;�....,,y,��,.s..••„ye���41':(f�-Fr�i.#..�T':+V7a►�YY�;' it*ti .K?`5k?'.s4.t'#i.:� ..+ ....:a.°,e"r..p'�+r.•ha"e� f°t7�+'o�c�e'�.Sc:z=�..� v+. .. :._ x.v-r,uw�=-r�.�o- - w-+ Page "10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM =INFORMATION (continued) . €. Property Address: ZOt� r QjA _ n Owner: Date of Inspection: ©/ 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. W f� r owl 10 r" 46. .10010 3, 10 r" 2L/ r 1� r b r Page 11 of 11 OAFICUL INSPECTION. FORM -NOT, FOR VOLUNTARY ASSESSMENTS "t` -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM..,.. ; } , , } PART C E 1. SYSTEM INFORMATION (continued).- • Property Aadress �.P inU fe.4 C4 h ,la min , T 4 OVE�. g Owner: Date of Inspection: SITE EXAM Slope ! Surface water 'Check cellar §h'allow. wells t Estimated de th to grouAd water "" jfeet nR>�•",!:: t ka e .,,� f�' ...# .' .i .:r. a''" f rr.4 � :`:-'. x .i .r.y � �',:. J,� ' Please indicate (check) all methods used to determine the high ground water elevation: �..ir+0$tained froiii s stem'desi plans on record - If checked, date of design plan reviewed: » '°Observed.site abutting property/observation hole within 150 feet of SAS) 'Checked with okal' Board of Iealth-explain: l ' ; '"' F -• Checked.with,rlocal zcavators, installers- (attach documentation) Accessed USGS database -explain: • t - r 1� r " Board� Health o SEPTIC SISTIIi i } Northk s8. TIGN C� LI LOT INS`!'ALLA , ovED DATE IiJCS9F'F 07ED IIAT � �XCAQA9 0$ 1. Distance Tos a. Wetlands b. Drains c. Well 2. Nater Line Location 3. No PPC Pipe ,r .. 4. Septic � Tank a. --Tees Length & To Clean Out Covers b. Cement Pipe to Tank - O Both Sides of Tank - 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6.- Leach Field or Trench a. Dimensions: b. _Stone Depth c.Capped ids d. Clean Double Washed Stone --- 7. - tone. -7.. Leach Pits- C. its a. , Di,msnsions • ' b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both. Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Tinal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Perc Test d. Elevations e: hater Table . E• SS Board of H ahh NorNort,h Andovers Mas s SUBMIFACR DISPOSAL DESIGN CHWK LIST APPROVED DATE AISAPPROM DAA — ---- __ Provided: Reasons: 3q 641, iti ® FAIL OX Rag 2.5 he submitted plan rpt show as a : the lot to he served-area,dimensions lot #,abutters location and log deep observation Mes-dietance to ties a l=ocation and rem33-ts percolation tests -distance to ties design calculations &c calculations showing requireA leaching area location and dimensions of syatem-including weserve area existing and proposed canes Ll location any wet areas t-itM-n IGO, of sang® (U- sposal system or discl.airer-checck wetlands mapping (h surface and subsurface gains -,I t`Idn 3.00 1 of ss-gge disposal system or disclaimer (i) location W draiwtge easements ulthin 100 ° of sercage disposal system or disclaimer-Plawang Board files (3) kaova sores of water supply w.tUn 2001 of setrage dispoa?.al - system or disclaimer tt o location of any proposed wal to serve lot -1000 from leacbing facility location of tater lines on property -101 from leaching facWtyr :. , � locaf..on of benchmark driveinys ) garbage di*osal.s _ no PVC to be used in construction _.. q) prr�f lie of �r.73tem-el tions of basement, plumb, pipe, se* tank, distribution box inl.ct s and outlets, dist buts on fi �.d piping ank nd df�c�� elevations �. -r"w" #:cum gran id vater elevation in area sewage disposal system s) plan wast be pmpamd by a Frofossianml Edgizeer or other professional authorized by law to prepare sw.h plazas Rog 6 Septic Tanks (a) capacities -_150% of flow.. meter table, tees, depth of tees, access., pureping ) clemout --,7 101 from cellar �nll or Ing mund st4mming Pel (d) 251 trom subsurface drains Reg 1®.2 Beg 10.4 Distribution Boxes a) s cpe greater than 0.08 b) sunp Reg 1.1.2 n.4 11.10 _ 11.11 Reg 15.1 15.4 15.8 3.7 Reg 14,1 14.3 14.4 14.6 14.7 Reg 9.1 9.6 4 snign Check List .�� P�� 22 FAIL I OK LeFach is Leaching pits a preferred :here the installation is possible a) calculation of leaching area- � sq ft b) spacing C) Surface a 2� d) cover eri,al e) � � x2 1 n splash pad f) tee ealbow g) no ds in pipe from dmbox to pipe LeachingPlelds, a) no greater than 20 mutes/inch area- 900 sq ft construction of field surface drainage 2 % e) 201 from cellar or ingrowid sudndng goof. Leaching F aches a) ca:. c a L ® eacbing areae 5DO aq ft b) spacing- ft nfim 6 ft with reserve between c) Awa$ s d) cons ction f) surfXce drai ge 2% unh)L �s,�lo.. �e a) s ®p Y,7: = `to be s s) b) 3�/x Z 150 = (to be shown) =:ja)mal. J b) lMd-by power