HomeMy WebLinkAboutMiscellaneous - 202 LACY STREET 4/30/2018,I
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PUBLIC HEALTH DEPARTMENT
Community Development Division
CERTI�FICArjE OAF' C0W�1'LIATVCE
As of:
November 8'2010
9his is to cettify that the individual su6sutace disposal system received a
SA27SFACrI0RTIJVS�PECZ709V'of the:
ftp&cew I of an
YNOSept c Oistri6ution Bob, for an
On Site Sewage �osaCSystem
By:
OaniefBriscoe
At:
202 Gary Street
Swap -105.0 2'a cel -0008
North Andover, WA 01845
The Issuance this cert�ate shall not 6e construed as a guarantee that the system will
function sg�torily.
`Y sauyei ?- i
Mealth (Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
"TOWN OF NORTH ANDOVER of AORTN
Office of COMMUNITY DEVELOPMENT AND SERVICES o? •'
HEALTH DEPARTMENT
%odd 4M OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 �'ss'„CN„s�`�
978.688.9540 - Phone
Susan Y. Sawyer, REHS/RS 978.688.8476 — FAX
Public Health Director E-MAIL: healthdept,atownofnorthandover.com
W EBSITE: http:' www.townofnorthandover.com
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; repaired;
T )6 6, e
(Print Name) dh l
40, located at a )- C
(Installation Address)
was installed in conformance with the North Andover Board of Health approved plan, originally
dated and last Revised on// , with a design flow of
,—
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 final 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.
Bed inspection date: /
o 41 9ox
Final inspection date:
Engineer Representative (Signature)
And - Print Name
Engineer Representative (Signature)
And - Print Name
Installer: (Signature) Date: lQ
�2
And - Print Name
Engineer: _ (Signature) Date:
And - Print Name
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,&GRIN , Commonwealth of Massachusetts Map -Block -Lot
-----------------------
0 Board of Health Permit No
North Andover BHP -2010-0755
-----------------------
P.I. FEE
�SsicMu�� F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Daniel -R. Briscoe
- ----------------------------------------------------------------------------------------------------
to (Repair -D -BOX REPLACEMENT -1-120 ONLY) an Individual Sewage Disposal System.
at No 202 LACK STREET
as shown on the application for Disposal Works Construction Permit No. BHP -2010-075 Dated November 04, 2010
-- --- ~— ---=------------------
Issued On: Nov -04-2010 f fBoard of Health
�«
as
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
rab
IL If
renin
1
Application for Septic Disposal System
Construction Permit -TOWN OF
t 1 1 G A MR4905 Will
Applicationis hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
//y�0
TODAY'S BATE
$ 250.00 — Full Repair
$125.00 - Component
❑ Repair or replace an existing on-site sewage disposal system*
Repair or replace an existing system component — What?
A. Facility Information ll -,21040
7-0.x Gee y J-7 . Ol/
Address or Lot #
Oe-
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2.
State Gode
q 7g g? / i'p e2'� 7
Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town
4. Designer Information
Name
Address
City/Town
A d X83 y
State Zip Code
�iS��s6yds-
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
Com,
N°Rr� Application for Septic Disposal System
? 6�1 i •o'r �
°pConstruction Permit -TOWN OF
► s
ORTH ANDOVER. MA 01845
• 09 r � �
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Buildinq:esidential Dwelling or ❑Commercial
B. Agreement
/o�y//a
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
00a
Name Date
Application proved By: oard of Health Representati e)
10 0
Name ` at
Ap lication Disapproved for a following reasons:
For Office Use Only:
L Fee Attached.?
2. Project Manager Obligation Form Attached?
3. Pump System? If so, Attach copy of Electrical Permit
4. Foundation As -Built? (new construction ronly).
(Same scale as approved plan)
5. Floor Plans? (new construction only):
Yes L/ No
Yes ✓ No
Yes
Yes
Application for Disposal System Construction Permit • Page 2 of 2
_90 r /'Ca`eH, eh-- on iy
l SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
tic stein S For plans by &/d
(Address o p y )
(Engineer)
Relative to the application of (fin ? Cl AZ
(Installer's name) And dated rignn
Dated / D /b
o ay s ate With revisions dated ���
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the apurz oved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
MY company.
a. Bottom of Bed — Generally, this is the first (1s� inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdel?t@townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, D -Box, p pes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer, understand that I am solely responsible for the installation of the system as per the
approved plans No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer:
�(b��i�%O%p (Today's Date)
TN Qnl l�
ame — runt(Nam—e—Signed)
Commonwealth of Massachusetts 4�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner owner's Name
information is
required for every N. Andover MA 01845 10/08/10
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Q
A. General Information
1. Inspector:
Name of Inspector
Aspen Environmental Services LLC
Company Name
270 Lawrence St
NOV -, wo
Company Address
Methuen
MA 01844
Cityrrown
State Zip Code
978-681-5023
2035
Telephone Number
License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes Conditionally Passes ❑ Fails
ing Authority
A� d
Date '/' .,,'—
_spection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
'"This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of AmericE
Owner's Name
N. Andover
City/Town
B. Certification (cont.)
MA 01845 10/08/10
State Zip Code Date of Inspection
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) Zstemonditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
information isN. Andover
required for every MA 01845 10/08/10
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The -system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system. is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 09/08 Tide 5 Official Inspection Farm: Subsurface Sewage Disposal System •Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
information is
required for every N. Andover MA 01845 10/08/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Pu>th
W r Supplier, if any)
determines that the system is functioning in a manneprotects the public health,
safety and environment:
❑ The system has a septic tank and soil a
100 feet of a surface water supply or tributary tc
❑ The system has a septic tank a/SAsupply.
ElThe system has a septic tank a
supply well.
;pffon system (SAS) and the SAS is within
.Irface water supply.
the SAS is within a Zone 1 of a public water
and the SAS is within 50 feet of a private water
The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or
more from a private water supply ell**.
Method used to determine dis ce:
** This system passes if
bacteria indicates absen
less than 5 ppm, prove
attached to this form
3. Other:
"ell water analysis, performed at a DEP certified laboratory, for coliform
Ind the presence of ammonia nitrogen and nitrate nitrogen is equal to or
that no other failure criteria are triggered. A copy of the analysis must be
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
lomlogged SAS or cesspool
❑ _ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins • 09/08 Tide 5 Oficial Inspection Form: Subsurface Sewage Disposal System •Page 4 of 17
N Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Ownees Name
informationis N. Andover MA 01845 10/08/10
required for every
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ E 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.
❑ Er-____ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Imo' 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.
❑ Li,V Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ -The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to a he following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system ' within 400 feet of a surface drinking water supply
❑ ❑ the stem 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 hav nswered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 09/08
Tide 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 5 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner's Name
N. Andover MA 01845
cityrrown State Zip Code
C. Checklist
10/08/10
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
E ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ [01 Were any of the system components pumped out in the previous two weeks?
❑ [9 Has the system received normal flows in the previous two week period?
❑ 2 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?
'Lf Was the site inspected for signs of break out?
❑ Were all system components, excluding the SAS, located on site?
dd' ❑ 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): —� Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
Information is
required for every N. Andover MA 01845 10/08/10
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes P --Wo
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 91--N-o
Laundry system inspected? ❑ Yes �o—
Seasonal use? ❑ Yes -[ilo
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. c.):
Grease trap present?
Industrial wasteholdin nk present?
Non -sanitary wa discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes Lj--Nu
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins • 09/08 Title 5 Official inspection Forth: Subsurface Sewage Disposal System •Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
information
fired is every
N. Andover
re wired for eve MA 01845 10/08/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records: tt
Source of information:i�-1/
Was system pumped as part of the inspection? ❑ Yes Ll--Iqo--
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of S tem:
Septic tanodistribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
information is
required for every N. Andover MA 01845 10/08/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
st iron a40 PVC ❑ other (explain):
1G //
feet
❑ Yes U-96-
Distance from private water supply well or suction line: 'S
feet y
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
concrete ❑ metal
If tank is metal, list age:
40ff,z 15- -1,2eet
❑ fiberglass ❑ polyethylene ❑ other (explain)
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
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
10/08/10
Date of Inspection
A 7 r/
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum
feet
fiberglass ❑ polyethylene ❑ other (explain):
top of scum to top of outlet tee or baffle
from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins • 09108
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
202 Lacy Street
Property Address
Bank of America
Owner
Owners Name
information is
required for every
N. Andover MA 01845
page.
City/Town State Zip Code
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
10/08/10
Date of Inspection
A 7 r/
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum
feet
fiberglass ❑ polyethylene ❑ other (explain):
top of scum to top of outlet tee or baffle
from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins • 09108
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Form
202 Lacy Street
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outle or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of ge, 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
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
Comments (condition
❑ fiberglass ❑ polyethylene ❑ other (explain):
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date
and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached?
❑ Yes ❑ No
❑ Yes ❑ No
t5ins - 09/06 Tifie 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
ection
Form
- Not for Voluntary
Assessments
Property Address
Bank of America
Owner
Owner's Name
information isequired or every
N. Andover
MA
01845 10/0$/10
page.
Cityrrown
State
Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outle or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of ge, 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
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
Comments (condition
❑ fiberglass ❑ polyethylene ❑ other (explain):
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date
and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached?
❑ Yes ❑ No
❑ Yes ❑ No
t5ins - 09/06 Tifie 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
U:
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
information is
required for every N. Andover MA 01845 10/08/10
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
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.):
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
Comments (note condition of pump cham
❑ Yes ❑ No
❑ Yes ❑ No
ition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Fonm
'u< 202 Lacy Street
D. System Information (cont.)
ection
Form
/
Lam' leaching pits
- Not for Voluntary Assessments
❑ leaching chambers
number.
❑ leaching galleries
number:
❑ leaching trenches
Property Address
❑ leaching fields
—
❑ overflow cesspool
Bank of America
❑ innovative/altemative system
Owner
Owner's Name
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
information is
required for every
N. Andover
MA
01845 10/08/10
page.
Cltylrown
State
lin Cnr1n n.*e „s
D. System Information (cont.)
Type:
/
Lam' leaching pits
number.
❑ leaching chambers
number.
❑ leaching galleries
number:
❑ leaching trenches
number, length:
❑ leaching fields
number, dimensions:
❑ overflow cesspool
number:
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
J
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 cess I
Materials of struction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • ogroe
Title 5 Official Inspection Forth: Subsurface Sewage Disposal System •Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
information is N. Andover MA 01845 10/08/10
required for every
page. Cityrrown 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 XX
Depth of solids
Comments (note /dition
etc.):
of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
t5ins - 09/08 Title 5 Official inspection Form: Subsurface Sewage Disposal System -Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner Owner's Name
information is
required for every N. Andover MA 01845 10/08/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand -sketch in the area below
LJ drawing ottached separately
t5ins • 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 15 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
Owner's Name
N. Andover MA 01845 10/08/10
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
-j
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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposaf System • Page 16 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Lacy Street
Property Address
Bank of America
owners name
N. Andover MA
Cityrrown State
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
01845 10/08/10
Zip Code Date of Inspection
El-SysInspection Summary D (System Failure Criteria Applicable to All Systems) completed
Q— te . Information - Estimated depth to high groundwater
Sketch of Sewage Disposal System
g peither drawn on page 15 or attached in separate file
t5ins • 09108
Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF EN IRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ,
Property Addresq: a C.l�►� ��/ $ �--
Nanot A S�
Owner's Name; L S
Owner's Address: wry. Lr%,CG�j
An+A�ti/r: h
Date of Inspection:
Name of Inspector: (please print)
Company Name:_ N. T. Whi e- Entererises, DBA HomePro Northshore
Mailing Address: P.O. Box 101
• Rnwl Pv Ufa _ Q,jc��g - '
Telephone Number: _ (08) 948—s4g8
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 f4netion and maintenance•Qf on site sewage disposal systems. I am a DEP
approved system inspector pursuant to S ction 15.340 of Title 5 (310 CM 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaldation by the Local Approving Authority
Fails,
Inspector's Signature: __ m, ' ;,,N,� _ AtiJt~,� Date:.
The system Inspector shall submit a copy of this inspgctlon 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. .
Notes and Comments
""*"This report only describes conditions at the time of luspection 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.
'Page 2 of 11:
• OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FORK!
PART A
CERTIFICATION (continued)
Property Address:.
Owner: .
Date otlnsp9ctlon:
Inspection Summary: Check A,B,C,D or B / LVAYS complete all of Section D
A, tot
sses:
found any information which indicates that any of.the failuro criteria described 143 10 CMR
15.303 or In 310 CMR 15.304 exist. Any failure criteria not evaluated arc indicated below.
Comments:
I System Conditionally passes:
Ono or more system components as described in the "Conditional Pass" section need to be replaced or
epaired, The system, upon completion of the replacement or repair, as approved by the Board of Health; will pass..
oswer yes, no or not determined (Y,N,ND) in the _,__, for th
xplain. e fo)lowing statements, If "not determined" please.
Tho septic tank Is metal and over 20 years old* or the septic tank (whether metal or not) Is suuct uaily
around, exhibits substantial Infiltration or exfiltration or tank failure is Immix nt, System will pass'inspection if the
casting tank is replaced a complying septic tank as approved -by the Board of Health,
A metal septic tank will pins inspection if it Is structurally sound, not leaking and If a Certificate of Cc plianco
.dicating that the tank is less than 20 years old Is available.
D explain:
Observation of sewage backup or break oq ori static water leve, in the distribution box dpe•to broken oC:,
,saucted pipe(s) or duo to a broken, settled or uneven distribution box, System w111 pass Inspection If (with
proval of Board of Health);
broken plpe(s).aro replaced
obstructions removed '
_••^• distribution box is leveled or replaced
explain;
The system required pumping more, than 4 times a year duo to broken or obstructed pipe(s), The system will
;714spectlon If (with approval of the Board of Health):
— broken pipes) are replaced
,..R, obstructions removed
explain:
1. Page 3 of i l
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: D LQ CE S
Owner: < A n
Date of Inspection:
C. Further Evaluation Is Required by the Board of Health: A
Conditions exist which roquire further evaluation by the Board of Health in order to determine if the system
is falling 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
2. System will fall 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 DBP 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 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
sr
' Page 4 of 11
OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
,PART -A
CERTIFICATION (continued)
Property Address: _ •.�G1- LA• Cpl/ --
►yri�rr _RwtLauvr�
Owner: _ „C ice,
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "noTto each of the following for &inspections:
Yes No ,
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
t: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'/ day flow
., _jZ Required pumping more -than 4 times in the last year NQT
of times pumped due to clogged or obstructed pipe(s). Number
_Any portion of the SAS, cesspool or privy is below high ground water elevation,
..be 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 I of a public well.
—1z 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 privatk.tvater
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEI' certified laboratory, for coliform bacteria and volatile organic compounds
Indicates that the well is free from pollution from that facility aid the presence of ammonia
nitrogen and nitrate nitrogen is equal to or le9 th p S pptn, provided that-n%other failure criteria
are triggered. A copy of the analysis•must be attached to this form.]
_16._ (Yes/No) The system fails. I have determined that one orr4ore of the above failure criteria exist as '
described in 3l0 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure,
E. Large Systems: '
To be considered a large system the system must serve a ficiiit
gpd• y with a design flow of 10,000 gpd to I5,000
You must indicate either "yes" or "no" to eachofthe foilow4"
(The following criteria apply to large systems in.additioa.taths 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 II of a public water supply well
Ifyou 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 shalt upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department,
.1y(
f �
4
• Page 5 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: b_La C E./ 5�--
Nc�RTH
Owner: _ C H�r�nt_� S tIAN
Date of Inspection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
JZ,,,_ Pumping information was provided by the owner, occupant, or Board of Health
L,"'iere any of the system components pumped out In the previous two weeks ?
.1L l/Has the system received normal flows in the previous two week period ?
_ . Have Iarge 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 ?
L7 - Was the site inspected for signs of break out ?
ZWere 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:
Yes no
,yExisting information. For example, a plan at the Board of Health. '
-Z— 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)(6)]
Page 6 of 11
OFFICIAL INSPECTION FORM-`KQT'FpR yLUNTARY ASSESSh%iEri1'S s�;:'
SUBSURFACE SEWAGE DYSPOSAIL"SYSTEM INSPECTION FORM
.MT,C `=.
SYSTEMINFORMATION
Property Address: C,LQ c ffS j
t a
Owner: _ c t�A(ZLe S ---
Bate of Inspection:
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms (design)t _±j Number of bedrooms (actual):
DESIGN flow.based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:_
Does residence have a garbage grinder (yes br no); n_d
Is laundry on a separate sewage system. (yes or no): ru 1(if yes separate inspection required]
Laundry system inspected (yes or no); ��
Seasonal use: (yes or no): rvv
Water meter readings, if available (last'2 years usage (gpd)): v F14
Sump pump (yes or no): n.v
Last date of occupancy; -�C ,` c t A
COMMERCIAUINDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): d
Basis of design flow (seats)persons/sgtetc.):
Grease trap present (yes or no): `
Industrial waste holding tank present (yes or no): N
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use; y'
OTHER.(descrIbe):
Pumping Records GENERAL INFORMATION
Source of information; _ t• -AS -t— —LY -1-4 <� .,
Was system pumped as part of the inspection (yes.or no 's 1 -.•4• Gv A�tcx 1
If yes, volume pumped: 1 gallons -- How aYas
Reason for pumping; qct' punqW 4CUrulhW?
..
TYPE OF SYSTEM ._.•,
V/ 1 eptic 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. Attacb 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:
IN Aa
�0 c,Lo — . a 4/
Were sewage odors detected when arriving at the site (yes or no): Xu
Ttati••1L t fr
. ' Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: aosr
IVt "k N•
Owner: c 0r+rLLG 5
1i cir
Date of Inspection: 17 / 3
BUILDING SEWER (locate onsite plan)
Depth below grade:_
Materials of construction: vcrast.iron �40 PVC other (explain): '
Distance from private water supply wel! or suction line: Ftx�t s e<4..+� c, wa c.�.t' Tc,
Continents (on condition of joints, venting, evidence of leakage, etc.): r w OrA40"C"r-
G� Amu SI %N v L1W 4VA&0
SEPTIC TANK: •_, (locate on site plan)
Depth below grade: ANte, 1 Ix"', %, 1-6/1
Material of construction: _jAoncretc _metal fiberglass polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no);
certificate),i (attach a copy of
Dimensions: -TO I i cow(, p �(,,1 c t cs-
Sludge depth: Trek 1 6� " 00/ 6A� &-v. a- Le -&A' S lbaw %C'e
Distance from top of sludge to bottom of outlet tee or baffle; 3a //- TAuK .3 y
Scum thickness: '�Tp.,►c I G 'e -rq ,r„ --
Distance from top of scum to top of outlet tee or baffle: ,7 y
Distance from bottom of scum to bottom of outlet tee or baffle: t / �A
How were dimensions determined: rl c -Lt* rig — `��""" i r TA�c ,'
G" M e AA Sr At N4 illi
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
►T ti rte. t����n - QZ3- ! LIL .GT "uZa-r-
ci�o 1 •.• r q�iY.� >3� r3. �� v
'VC-
GREASE
vimGREASE TRAP: —(locate on site plan)
Depth below grade:
Material of construction: —concrete ,metal `fiberglass ,_polyethylene other
(explain):
Dimensions:
Scum thicknessr
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:
Continents (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
4-
Page 8 of i 1
OFFICIAL INSPECTION FORM —"NQ TOR- VOLUNTARY ASSESSNWN A' 'f
SUBSURFACE SEWAGE DISPOSAL'••SySnM INSPECTION -FORM,
PART C
SYSTEM INFOkMATION (continued)
Property Address: _Qi a3.,
n• r,
Owner: c E n-"
Date of Inspection: , „
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: ` wt
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: allons L
Design Flow: aallons/day AI Jy
Alarm present (yes or no): !!
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover; any evidence of
leakage into or out of box, etc.):
�-- �-tiv,v c.. — p ai i u")c.ti, t�,f�• � la 4t_,r�1 L -- Nu � Lt,+D c NC tr"y-¢ .
I N 06 ac,Jr
PUMP CHAMBER: (locate on site plan)
Pumps in working order (yes or no): N
4
Alarms in working order (yes or no):
Comments (note condition of pump charnber, ceinilid6p`um
ofps'aod appurtenances,
%o
r
8
Page 9 of 11
OFFICIAL INSPECTION FORM —NOT IFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. C
SYSTEM INFORMATION (continued)
Property Address: -y 1 C_�-
H 1�1✓' v
Owner: c �n LF I ,
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
aching pits, number: A UL- P "t S 3 c. f /l � �, ��, G ►� rt y � �
leaching chambers, number: 0
leaching galleries, number: P i T i=
leaching trenches, number, length: P •1--
leaching fields, number, dimensions:
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.):
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 or no):
Continents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRrVY: (locate on site pian)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition ofsoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
We f
t t-S1gF-
UIFp 31/1
Page lOofil
OFFICIAL INSPECTION FORM VOLUNTARY ASSESSAUMS
SUBSURFACE SEWAGE DISPOSAL
SySitM INSPECTION FORM,
SART: C -
SYSTEM INFORMATION (continued)
Property Address: anfL L -Ac -c -q 5-1
Olt -,r% r t4 - _AAI
Owner; Limx- LtAA4
Ia
Date of Inspection: I L 3 lai4-
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system Including ties to at leastJ,
two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
10
0
.1 .
PIT
-3>
r
G
14
-6
10
' • Page l l of 1 i
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: L-q.S e%_
1✓.;{ w v
Owner: c: Lin
Date of Inspection: ,
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 1 d feet
Please indicate (check) all methods used to determine the high ground water elevation:
VObtained 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)
Accessed USGS database -explain:
You must describe how you established -the high ground water elevation: ,
v L rUw ',,,r =,� t �ti rc S'lun. 3 R,c,ivl�
7
11
�= P k-r-
�,
HOGAN., Danielp Jr.
Lacy St.
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Legj Street . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%, I will install a con-
crete septic tank of ima P&I.in size. A manhole (s) permitting easy cleaning
will be provided with remova le cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a -series of trenches, the bottom of which will pro-
vide a minimum of 200 lineal (%%UM) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/$" to 1/41, (dia.) will.be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any Stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
rection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE ^
i n ure of ant
I hereby issue the above permit for the,Board of Healfof the Town of North
Andover, Massachusetts.
DATE
Siddatfire of Health Agent
CT
I have inspected the uncovered system indicated above and find everything done
as described.
DATE 17 I l �t .
dT
Signature ofUnspecting Officer
Percolation Test 7 min., Soil= Sandy clay
Garbage Grinder No
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
n
1, NAME
2. ADDRESS
DATE
LOT NO. TEL.
3. NO. OF BEDROOMS DEN YES NO
4. GARBAGE GRINDER YES NO
5• SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
'I- SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE JanuEy 25 1964
NAME OF APPLICANT _ .Hogan, Danieli gr.
LOCATION._ �aoy Street
--Address of lot no.
BUILDING: Dwelling Other
SYSTEM: New X .Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel_ San la
PERCOLATION TEST 7 minutes per inoh.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1,000 gallon capacity.
LEACH FIELD 200 lineal feet of drain pipe.
OX -41-M" JT
William --J, iscoll, Engineer
Board of Health
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 or requirements.
APPLICANT FILLS OUT THIS SECTION
APPLICANT �h u ► L. PS it a� PHONE S 7f -/4/C,
LOCATION: Assessors Map Number / QC PARCEL
SUBDIVISION LOT (S) -�
STREET L u ST. NUMBER 2G Z
**OFFICIAL USE
- RECOMMENDATIONS OF TOWN AGENTS: /Q X Ax 1-110 is
CO S RVATION
,TOR DATE APPROVED
DATE REJECTED
R1t'.
COMMENTS ��� i,, G`- 1
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
. X .
4.5
144
HOGAN, Daniel, Jr.
Lacy St.
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
L.cy Street . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 296. I will install a con-
crete septic tank of I000 gal, in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 9nn lineal () feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE (9,�, Z-1 /_
a
ign ure o punt
a
I hereby issue the above permit for the.Bord of Heal of the UTown of North
Andover, Massachusetts.
Sidi}ature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE .7 f�
�q
Signature of nspecting Officer
Percolation Test 7 min. Soil: Sandy clay
Garbage Grinder No
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
I
1. NAME,- t DATE
2. ADDRESS LOT NO. TEL.
y
3. NO. OF BEDROOMS ! DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9, NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE January 25, 1964
NAME OF APPLICANT Hogan, Daniel, Jr.
LOCATION Lacv Street
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X, Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel Sandy Olay
PERCOLATION TEST 7 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1,000 gallon capacity.
LEACH FIELD 200 lineal feet of drain pipe.
ri
William J. DPiscoll, Engineer
Board of Health
SOIL P;OFILE & PERCOLATION TEST DATA
' Board of Health -North Andover, Mass.
Street _ -- Lot No, ---i 2
Subdivision' Owner
Investigator Observer
SOIL PROFILES
1 . Date 2. Date 3. Date_
Elev. Elev. Elev.
Feet Inches
'0 0
4. Date-
Elev.
Ties to Test Pits
1.
2.
3.
4.
Tote: Top & subsoil depth; depths of other soil tees; depth 'of water table;
depth of refusal.
T PERCOLATION TESTS
�J
sl -�-'7/ Il 1 !:i 1 . P T A Tia'{- C] 117 i- P -
it Number
1 2
3
4 5 -
tart Saturation
oak --MJ ns.
tart Test-Time.--�--
rop of 3" -Time
rop of 6" -Tim
-I
..-ns. st 3„ Drop
is. end_ 5 i,rr,p
- _-
•
J
SO: T, PROFILE & P=ERCOLATION TEST DATA
Board of Heal -V --North Andover, Mass. r
S u r e eU
U . D Q
2
Subdivisi, 0-11'
Owner
Saturation
Investigator
Observer—
Date
Elev.
F e e. -L Inches
D 0
[us
SOIL PROFILES
2 Date 3. Date
Elev. Elev.
Tot -e: Top & subsoil depth;
depth of refusal.
PJ
S1
C-1
4. Dat e___,___
Elev.
Ties to Test Pits
depths of othe'r soil types; -depth of water -table;
PERCOLATION TESTS
T)p t, P Rq t: P T)R t-, P T) R f -, L- Tate
t Number
2
4
Saturation
.-art
s
,op
of 3" -Time
0- P_
of 6 ime
ns.
'1st 3" Droj)
ns.
2nd 3" Dj-,oT)
ODy T,0 S
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
-= K NORTH ANDOVER BOARD OF HEALTH
APPROVED DATE PROVIDED
Title 5
Reg. 2.5
Reg. 6
Fail
DISAPPROVED DATE TIME REASON
The submitted plan must show as a minumum:
a the lot to be served (area,dimensions,lot ;,abutters)
(Planning Board files)
,_� location and log of deep observation holes -distance
to ties
,_4_e ---location and results of percolation tests -distance
,=,5�o ties
design calculations & calculations showing required
leaching area
__(e_)_�ocation and dimensions of system (including reserve
area)
--() existing and proposed contours
(g) location of any wet areas within 100' of the sewage
disposal system or disclaimer (check wetlands mapping)
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
---(-k-) 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
('n) -driveways
-, o� garbage disposers
--�j. no PVC is to be used in construction
___(-�a profile of the system (elevations of basement, plumber:
pipe septic tank, distribution box inlets and outlets,
distribution field piping and any other elevations)
--E--r) maximum ground water elevation in area of sewage disposa:
. system
_--k-s— plan must be prepared by a Professional Engineer or
\. other professional authorized by law to prepare such
plans
Septic Tanks
(a) Capacities - 150% of flow, water table, tees, depth
of tees, access, pumping,
Cleanout
(c) 10' from cellar wall or inground swimming pool
(d) 25' from subsurface drains
North Andover Subsurface disposal system check list - Page 2
Fail OK Distribution Boxes
Reg.'10.2Slope greater than 0.08
Reg.10.4 (b Sump
Leaching Pits
Leaching pits are preferred where the installation is
possible
Reg.11.2
) Calculations of leaching area (minimum 500 S.F.)
Reg.11.4
-) Spacing
Reg.11.1
Surface drainage 2%
h_eg.11.11
d Cover material
2 t�F" plash P -d
n� ��� �``' � � `� fir
-1;neach
Fields
Reg.15.1
(a) N,Greater than 20 minutes/inch
Reg.15.1
(b) Area (minimum 900 S.F.)
Reg.15.4
(c) Construction of field
Reg.15.8
(d) Surface drainage 2%
Reg. 3.7
(e 20' from cellar wall or inground swimming pool
Leaching Trenches
j Reg.14.1
(a) Calculations of leaching area (min. 500 S.F.)
Reg.14.3
(b Spacing (4 ft. min. 6 ft. with reserve between)
Reg.14.4
(c Dimensions
14.5
Reg.14.6
(d) Construction
Reg.14.7
(e) Stone
Reg.14.1
(f) Surface drainage 2/
Downhill Slope
Slope y/x = (to be shown)
(b) y/x X 150 = (to be shown)
PumE�
Reg. 9.1
(a) Approval
Reg. 9.6
(b) Stand-by power
BOARD OF HEALTH OF NORTH ANDOVER$ MASSACHUSETTS
SEWAGE DISPOSAL
DATE
NAME OF APPLICANT Rev_ Arthur White
LOCATION Lacey St., No. Andover - Boxford Line
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X Repair
GENERAL DESCRIPTION OF LAND hip -h
SUBSOIL: Clay Gravel X Sand
PERCOLATION TEST i minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1.000 gallon capacity.
LEACH FIELD 180 lineal feet of drain pipes
William J. l i colli Engineer
Board of Heal
CONSERVATION COMMISSION
NORTH.ANDOVER, MASSACHUSETTS 01845
• APAIL7M
e. 18'35
November 20, 1978
North Andover Board of Health
Town Hall
North Andover, Massachusetts 01845
RE: Lot 19 -Lacy Street
reported as Lot 12 -Lacy Street to Board of Health
Dear Sirs:
The Conservation Commission has received a Notice
of Intent under the Wetlands Protection Act for the
above referenced lot. During a routine site visit, as
part of the responsibilities under the Wetlands Protection
Act, a discrepancy was noted between the soil test data
report on the subsurface disposal system plan, and an
open soil test pit on the site. This plan was.submitted
to both the Conservation and the Board of Health.
Because of the differences noted above, it was con-
sidered advisable to inform you of this discrepancy so
that you might investigate, if you deem it necessary.
VST/dlp
Very tryly yours,
Vincent S. Turano, Ph.D.
Chairman