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HomeMy WebLinkAboutMiscellaneous - 205 CAMPBELL ROAD 4/30/2018%�- -100 I 1�7e7Z North Andover Board of Assessors Public Access NO DTM ,� Ot t•�a N 1t ,(, � • COW Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 North Andover Board of Assessors 2+ roperty Record Card Parcel M :210/106.B-0052-0000.0 FY:2009 Community: North Andover ttion: 205 CAMPBELL ROAD ter Name: HARRISON, JOSE E LOREDANA M HARRISON ter Address: 205 CAMPBELL ROAD City: NORTH ANDOVER State: MA Zip: 01845 Aborhood: 7 - 7 Land Area: 1.04 acres Code: 101-SNGL-FAM-RES Total Finished Area: 1850 sqft ASSESSMENTS :al Value: ilding Value: id Value: rket Land Value: ipter Land Value: CURRENT YEAR 415,700 190,600 225,100 PREVIOUS YEAR 415,700 190,600 http://csc-ma.us/PROPAPP/display.do?linkId=1465260&town=NandoverPubAcc 3/3/2009 Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form JUN 24 2015 I�,y - Not for Voluntary AssessmenjtWN OF NORTH R Subsurface Sewage Disposal System Form ry � HEALTH DEPARTMENT V 205 Campbell road Property Address I nri Hnrrincn Owner Owner's Name information is North Andover MA 01886 June 9,2015 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive Company Name � 58 South Kimball street Company Address Bradford City/Town 978-372-7471 Telephone Number B. Certification MA State S113386 License Number 01835 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 F rther Evaluation by the Local Approving Authority une- 9-, do15 Signature Date Thestem inspector shall submit a copy of this inspection report to the Approving Authority (Board of H alth or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 41 Commonwealth of Massachusetts 92) Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address I nri Hnrrinsn Owner Owner's Name information is North Andover MA 01886 June 9,2015 required for every page. Cityrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts _ u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 205 Campbell road Property Address I nri Harrinsn Owner information is required for every page. Owner's Name North Andover MA 01886 June 9,2015 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Dist box needs replaci ❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 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 205 Campbell road Property Address Lori Harriosn Owner's Name North Andover MA 01886 June 9,2015 City/ -town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '4M ; 205 Campbell road Property Address Lori Harriosn Owner Owner's Name nformatl is required for every North Andover MA 01886 June 9 2015 for page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 i ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is North Andover required for every page. City/Town C. Checklist MA 01886 June 9,2015 State 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 l5ins - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is required for every North Andover page. City/Town D. System Information Description: Number of current residents: State 01886 June 9,2015 Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) 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: ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No ® Yes ❑ No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: State Zip Code General Information Date June 9,2015 Date of Inspection Source of information: Stewarts Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site guage on truck Reason for pumping: Inspect tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts u r Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) MA 01886 June 9,2015 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 46 vears Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 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) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is North Andover required for every page. Cityrrown l5ins • 3/13 D. System Information (cont.) MA 01886 June 9,2015 State Zip Code Date of Inspection 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 30" 1" 6" 14" How were dimensions determined? tape measure & sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles good no leakage liquid levels good. 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is required for every North Andover MA 01886 June 9 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.) * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is required for every North Andover MA 01886 June 9 2015 page. City/Town 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.): Dist box broken around outlet inverts need replacing. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 01 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is North Andover required for every page. City/Town MA 01886 June 9,2015 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 1-20X60 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.): no hydraulic failure, no ponding, no damp solis. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 EM Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner's Name North Andover MA 01886 June 9,2015 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is required for every North Andover page. City/Town MA 01886 June 9,2015 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand -sketch in the area below ❑ drawing attached separately t5ins • 3/13 Title 5 Official Inspection form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts u r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) State Zip Code June 9,2015 Date of Inspection Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4'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: 9/6/67 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Pulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Took slots from low area bottom of bed aprox 2.5' above water table. Bottom of foundation with pump avrox 2' below bottom of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts N - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Campbell road Property Address Lori Harriosn Owner Owner's Name information is North Andover required for every page. Cityrrown MA 01886 June 9,2015 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Stewart's Septic Service ❑ Andover Septic ❑ Stratham Hill Septic (978) 372-7471 (978) 475-2593 (603) 772-5548 58 South Kimball Street, Bradford, MA 01835 a ❑ Roto -Ram (978) 452-9022 �yef 6vi `� PAY FROM THIS BILL Customer Name: 4r r if S ❑ Reg. Nature of Service ❑ N/C Q Reg. Maint. Se -' e c tiQa ❑ Emergency Septic Tank Pumping and Cleaning ❑ Day ❑ Night Phone: "Done the Right Way" Contact: Not Responsible for Covers Billing Address: or Irrigation Systems C,Y: , Zip: Special Instructions Completed Z Incompleted Reason: Per: AM/PM Services Rendered Vacuum Pumping Observations Drain Cleaning Septic Tank Good Condition ❑ Main Line ❑ Drywell ❑ Leechfield Runback ❑ Toilet Bowl ❑ Leech Pit / Overflow ❑ Riding High ❑ Kitchen Sink ❑ D -Box (liquid level) ❑ Bathtub / Shower ❑ Pump Chamber ❑ Full to Cover ❑ Vanity ❑ Grease Trap ❑ Excessive Solids O Floor Drain ❑ Catch Basin Top / Bottom ❑ Vent ❑ Portable Toilet ❑ Use No Powdered Soap ❑ Sewer Jet ❑ Other ❑ Heavy Grease ❑ Other Qty: ❑ Roots Footage: Size: ❑ Suggest Electric ❑ Under 1000 gallons X 1000 gallons ❑ 1500 gallons Rootering ❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ Van Called ❑ 5000 gallons ❑ Other ❑ Other Misc. ❑ Digging Charge ❑ Backhoe ❑ Inspection ❑ Location ft./in. ❑ Consultion hrs. ❑ Certification: P/F ❑ Service Call ❑ Estimate Reason: ❑ Labor ❑ Portable Toilet Rental ❑ Pump Repair ❑ Waiting Time ❑ Baffle ❑ Repair * Digging Charge is Per Driver ❑ Chemical Treatment Discretion ❑ Other Description of work Recommendations Terms of Payment Parts Vacuum Pumping Drain Cleaning Yr. Month Yr. Month NET 15 DAYS Tax Terms &Conditions ❑Cash ❑Check L) Credit Discount Total 1. Not responsible for damage beyond curb line. 3. 1.5% per month will be charged to accounts past due. 2. All complaints shall be reported within 48 hours. 4. The purchaser agrees to pay all cost of collection. Customer Signature Serviceman —k�, rt t 0 H O M C: M: 00; � � N � � N O a 0 o c o z z O z Y C 0 Q Q U L U c� O pa � o 0 H x O a s. O pa � o 0 .n a) ZcaOi 1� CD � 0 r CD CD o � o o d 0 W o D m Q O z -n o CL 0m m v o � � CD CD to 0.o O 00 OU M O a 0 ID Co �\ o 4.9 cn� o0 N O W O C) CD0 1 O A 0 n ' ll n seD� z I � Vi01 A' � I I S b b�iV1'd.b I O O I Imo. CD C O O �`' vC, ft f fDfD n j •• _ j to Cueb CD o � j j I i 'o0 � �. CD j olo tj ' Olw A,00 I p I I i I i j I I � I I II i� eD p•I N N a=a�' b >.; ro o �ztzz' M r e m �r 0 r� I boy y� i boy I I o j 00 A • °� Application for Septic Disposal System Construction Permit —TOWN OF NORTH ANDOVER, MA 01845 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ream Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal sys m* epair or replace an existing system component — What? A. Fac Itx Information, TODAY'S DAT $ 250 air 125.00 - Compo ent Address or Lot # / City/Town 2.- *TYPE OF SEP IC SYSTEM*: ➢ ❑ Pump B7Gravity (choose one) ***If pumesysWn, attach copy of electrical permit to application*** ➢ onventional 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) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before D WC issuance) What is the Make? Owner Information .-a r/ Name Address (if different from above) City/Town Email address What is the Model. StateZi7 ^ z9�' 5� !/ ^ Telephone Number 3. Installer Information 3r Snw�vi s Se- 0TF G Name )/' Name of Company �I- VC,-/ City/Town 4. Designer Information Name Address City/Town St to Zip Code 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 •,.��w •. Application for Septic Disposal System ' Construction Permit -TOWN OF TODAY'S DATE .00 — Full Rpair NORTH ANDOVER, MA 01845 $ 25.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or ❑Commercial B. Agreement 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 Enviromental Code, as well asa Local Subsurface Disposal Regulations for the Town of No rt An ove .ferstan atuntil a final Certificate of Compliance has been issued by this o d of he i tailed system is not approved. N Dat Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump S sy tem? If so, Attach copv ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout. 4. Reviewed approval letter, all paperwork received? Yes No 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North And ver licensed installer for the construction for the septic system for the property at: Q� L (Address of septic system) For plans by Relative to the application of lo L J jaGQy`-,-� 0 (Installer's name) Dated o ay s ate And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 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 approved 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 (ls� 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: healthdeptnto-,vnofnorthandover.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 Healtb staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump cbamber, retaining wall and otber components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved 121ans. No instructions by the laorneovmer. general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: n (Tya)z'�s ate ame — PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 7/9/2015 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: of this Mychele Grant Public Health Agent Repair of D -Box By: John DiVincenzo At: 205 Campbell Rd. Map 106.B Lot 0052 orth Andover, MA 01845 shall not be construed as a guarantee that the system will function satisfactorily. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 205 Campbell Rd. MAP: INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D -Box INSPECTION: lm, 6 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: LOT: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned 11Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement 0/nstalled on stable stone base [H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ["�draulic cement around inlet & outlets bserved even distribution ❑ peed evelers provided (not required) edule 40 PVC Pipe Commonwealth of Massachusetts Map -Block -Lot 106.80052 >`} BOARD OF HEALTH Permit No North Andover BHP -2015-0286 ----------------------- FEE $125.00 DISPOSAL WORKS CONISTRUCTION PERMIT Permission is hereby granted John-DiVincenzo to (Repair) an Individual Sewage Disposal System. at No 205 CAMPBELL ROAD as shown on the application for Disposal Works Construction Permit No. BHP -2015-028 Dated June 26, 2015 --------------- ------------------- DY Issued On: Jun -26-2015 BOARD O HEALTH .........................'. ,........................................................................... :}unouay AdOo SAN3If111 W dd3a 00'SZi� .......................... uanwpielg 1jsi7 :Ala pan!aoa1d TEW :ON P9gO ozuaau'AtQ ugor C �.... anp ia3 :up Iln� u! pled _IOZ 9Z --•-••-••--•••--•..........-•-•--•-•--••-....... . at9dag wauoduzoD-3M(1 •........................... . ££8I00-SZOZ-Dau :ON ld!aoa� ZIL��d :9dl(1 aaJ 00.01SOyl,i00i00t :ON lun000y ......... HZ'I��H �O QHV0ff aanopu g�ao� Vew}ieda4 98Z0-Si0Z-dIlg SfiZ Q1v02I'I'Iagdw," ................ -rHg 9£0000-SiOZ :ON 90uaaa0�1 L .................................................... . Commonwealth of Massachusetts Map -Block -Lot 106.80052 >`} BOARD OF HEALTH Permit No North Andover BHP -2015-0286 ----------------------- FEE $125.00 DISPOSAL WORKS CONISTRUCTION PERMIT Permission is hereby granted John-DiVincenzo to (Repair) an Individual Sewage Disposal System. at No 205 CAMPBELL ROAD as shown on the application for Disposal Works Construction Permit No. BHP -2015-028 Dated June 26, 2015 --------------- ------------------- DY Issued On: Jun -26-2015 BOARD O HEALTH _C_\ Commonwealth of Massachusetts C i ty/Town of /�%6 . f'1Ci 0 Ve �'�' System Pumping Record Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System at' on the computer, use only the tab key to move your Add s cursor - do not 0 use the return' - key. City own VL��� 2. System Owner: - P-1 /_ Name — - — JJUL I 3 Z(]M renes GF n DevER Address (if different from location) � n v HEALTH DEPARTi�itPdT City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 1040 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): —N RECEIVED 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumpy: t iC Name Stewart's Septic Service Company If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 HUSETTS- lla. N1pvla90 jPfll form .or use b p u�rAKrM1 N( be subminvd fo tha Iocal 60a of Hoalch or olher�a �' e 5Y3(em Putr,p'�� a approving aulhorlty, A; Faculty .lnforri -q on --_ 9 oul ....1 .. System LOr8U0n; Cn � W,l lne LO koy A4dres4 - `us+'UH ntum�'.;;•�•„=''): ,Cty/i;atm .. ,; ' ;. r. S a!� ' ;,,al '1•, r v p Cove d';Syslam Ole �' •'1' ., '..'i/„:Yi,, �.r,' ,r,�' � � fir. _ . ;r'. �� .�. 1�f'I'ir•'.'r'1i. f.. ����.�-. '. I;i;�r�'.; :.,� �, .-. /fit/�/'” '�J l i AddreN (11 worm! turn louuon) Tclepnane NumOo( -- t c RUmping.Reqord' h - ---- `" Do,e2. QuanJry Pumped: -- :'; ' ,3, .7YP.a Pf.ayslam�•, �' .. c uon, i<:' ., , ❑ Ce99p001(9) i Septc Tank ti•c' ❑ Tight Tank ep- lea Fl (fivaril ue r.,• (.pr.�senc?..❑ Y No If 91 can • : li; .:,,�:.: "'` Y,,. l;; yes, was f cl ad? ❑ Yes ,;:6..1;Cofidl�lon.Q(9Y.>' ,'•�iJ'1!� jflyf,,4,r l /A:;irl y,l Ire -,.._s :'�'•:': `;, 's,..';.sy Pumped ey VehlcJe Ucen�e Number — .� �") I l�'�'.IY•�r'iI�1,11,j1�i+�•'ItI.i,�..l, J! r n.where'co(1lenls'Were d005ed; h4)/wwtivmas4,90v/de}p!wsle�/approva�s/16(orm9,hlminspec! Syt;am Pwnp'np Recd, 00 , blfll j If IWM!9l +0 ;, !p;of Boars , Q HEALTHDEPARTMEP {Iod to V1 r IpC, 1 8c+1 A. r.. .� r r •,, l: (•1 nOJlln pr CIn r .V /�.�, , acllltyInlorm�ulon 1� .�,:6,:Pumplllg:,�a�ord {, 00(o 01 Pvmpinp., .. . �r rYPe i.i _. 97fe- ; T1ll9n9n, n•moil — 07 Cel>9001(�)$optic T8n, esc• beJ, Too' F;1(e(p,1,vraont? [' Yo , no 1 e 11,Y��5r4.��h)Il��rrItie,"',,�, � 1Y9).n 311C'9anep% � YDS • ;'/' 'll,y:'t��+lr'r'/,J'1 �,�•11��5 I.r�'!V�r' �•-�` � �,( - ir�l,�.�1ur5�;• • v, pot, 8y .. 1 , i ..flys i • �@`fer ld # ,5, C t ¢ 4 y 1,v ��'1•r �t if �1}�iG !� #%/slik c•'r. d �J t to Its'* Sr Q / Ilk tv .Olt p ( ' aro Opoaoo: , M } (y%!ir�t•Ir•,,rrrl.• w sa.porldep�eierlep��9Yi�allblorm�,rr:�nain��' c{ � oll! '1 • o Sy WJr;1.0,'1lt.Yd'1,'.,�1„r1. •� •' J;' 4• �,";:''� SII �•1''i.•��'!; 'rQ;�(r';s45rrl�;�,,�t`,"1/1,,.,,,. `((.•,I,;I.:r:v�� .. S t 11 b''1'� r,h lY qrll .l•'r.l. •;�' i ',1'Ilk 1,I�Mr .r1'i,l,��ilrr .`F r I"111.1'r''•V•11 � � �Yrl .51,1 Il' •�'•., 1 \/w�„`K 41µ+ (IIO Irinl rA'nSlowVvn) VV �� .�,:6,:Pumplllg:,�a�ord {, 00(o 01 Pvmpinp., .. . �r rYPe i.i _. 97fe- ; T1ll9n9n, n•moil — 07 Cel>9001(�)$optic T8n, esc• beJ, Too' F;1(e(p,1,vraont? [' Yo , no 1 e 11,Y��5r4.��h)Il��rrItie,"',,�, � 1Y9).n 311C'9anep% � YDS • ;'/' 'll,y:'t��+lr'r'/,J'1 �,�•11��5 I.r�'!V�r' �•-�` � �,( - ir�l,�.�1ur5�;• • v, pot, 8y .. 1 , i ..flys i • �@`fer ld # ,5, C t ¢ 4 y 1,v ��'1•r �t if �1}�iG !� #%/slik c•'r. d �J t to Its'* Sr Q / Ilk tv .Olt p ( ' aro Opoaoo: , M } (y%!ir�t•Ir•,,rrrl.• w sa.porldep�eierlep��9Yi�allblorm�,rr:�nain��' c{ � oll! '1 • o Commonwealth Of Massachusetts = City/Town ®f North Andover System Pumping Record Form 4 wy DEP has provided this form for use by local Boards of Health. Other forms may be used, but the vided here. Before k with your information must be substantially the same as that prousing Reco d must be submitted o local Board of Health to determine the form they use. The System Pumping the local Board of Health or other approving authority within 14 days from the pumping, date in accordance with 310 CMR 15.351. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. d mum A. Facility Information 1. System Location: Address Ma 01886 North Andover State Zip Code CitylTown 2. System Owner: Name Address (if different from location) City/Town State Telephone Number Zip Code B. Pumping Record (,( 2. Quantity Pumped: Gallons 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): If. es, was it cleaned? E] Yes ❑ No 4. Effluent Tee Filter present? El Yes E] No y 5. Condition of System: 6. System Pumped By: 1-4/, i /y1 vehicle License Number Name Stewart's Septic Service Company \ 7. Location where contents were disposed: \ Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Date ©t Signature of Hauler Date Signature of Receiving Facility y/ System Pumping Record - Page 1 t5form4.doc- 03/06 Commonwealth of Massachusetts f u . City/Town of NORTH ANDOVER Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. L ieMn System Pumping Record Form 4 :�11t1 DEP has provided this form for use by local Boards of HealtPOther.formns may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: Address ,rte t �: • Ir , City/Town 2. System Owner: I . A '! Ir' Ir a f• .J Name Address (if different from location) City/Town State Telephone Number B. Pumping Record ioll � //- 5 1. Date of Pumping Date— 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) ,`Septic Tank ❑ Tight Tank F] Other (describe): Zip Code Zip Code /Ooc) Gallons [] Grease Trap 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: N aMf Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Sig t Hauer Date Signe -o-Receiving Facility Date t5form4.doc• 03106 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover w° System Pumping Record Form 4 O M 5 2013 W.7%, ER Ft�s1LTf•? ���.�-; �x�� DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health'to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. City/Town Ma State State Telephone Number 01845 Zip Code Zip Code B. Pumping Record 1. Date of Pumping 2. QuantityPumped: p g Date p Gallons 3. Type of system: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. ystem Pumped By: \/e- Nagy ' Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 nature Ibf Hauler Sig ate / Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor - do not North Andover use the return City/Town key. 2. System Owner: Name MW Address (if different from location) City/Town Ma State State Telephone Number 01845 Zip Code Zip Code B. Pumping Record 1. Date of Pumping 2. QuantityPumped: p g Date p Gallons 3. Type of system: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. ystem Pumped By: \/e- Nagy ' Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 nature Ibf Hauler Sig ate / Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Tuesday, March 03, 2009 10:19 AM To: loseharrison@verizon. net' Subject: 205 Campbell Road - Septic File from the Health Department of the Town of North Andover Attachments: SKMBT_60009030311030.pdf Hello Mrs. Harrison, It was a pleasure to speak with you today at the counter. As I mentioned, here is the scanned copy of your file for your records. Please call the office if you have any questions. Pamela DelleChiaie Health Department Assistant Town of North Andover 978.688.9540 - Phone 978.688.8476 - Fax From: noreply@yourcopier.com [mailto:noreply@yourcopier.com] Sent: Tuesday, March 03, 2009 11:04 AM To: DelleChiaie, Pamela Subject: Message from KMBT 600 1 I Commonwealth of Massachusl M:' k Massachusetts stem AU'MRInz Record %Cep, 6Ln4lzv, 112w - System Location JUL 0 5 2007 'VVN OF NORTH HEADPA�t i t , Type: Emergency 0 Routine Cesspool: No 0 Yes 0 Septic Tank: No 0 Yes Date of Pumping U Quantity Pumped � allons 1 System Pumped by (Company) Permit # Contents transferred to; 0 .f, Contents disposed at; �o , S A// Date l�' r Signa tore Pumpc of�em/ ther comments: Commonwealth of Massachusetts �l 6 City/Town of NORTH ANDOVER, MASSA - System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key' to move your cursor - do not use the return key. ranm DEP has provided this form for use by local Boards of Health. The be submitted to the local Board of Health or other approving authori A. t-acility Information AUG 0 4 2006 1. System Location: Address - - --- — -- — - City/Town State Zip Code — - 2. System Owner: Name Address (if different from location) city/Town B. Pumping Record 1. Date of Pumping Type of system: ❑ ❑ Other (describe): State Zi Code ----- -- - Telephone Number - - 2. Date Quantity - Y Pum ped: ------- — - Gallons Cesspool(s) L7 Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes X No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6. Sy em Pumped By: Name1 Vehicle License Number Company 7. Location where contents were disposed: - - --- - - --. l/ Si ature of Haul -- -- Date http://www.mass.gov/dep/water/ provals/t5forms.htm#inspect t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 TOWN OF NORTH AN_D0VE UA ll SYSTEM PUMPINQ RECOR.L �Clrr'i sari 676,5 - Mo. onalove-e-1 -1 ---------- - SYSTEM b6CATI0N Of RECEIVED JUL - 6 2005 NORTH ANDOVER f. -i DEPARTMENT DATE OF PVWNO. -___._.-__QUANTITY PUMpg[)._,_.q5Z YES $optic l'Ink. No. yds k- NA rUK4 OF SERVICE: K(>unNv)__ 0b3IAVA,nom: OOOD CONDITION KFULl..� LOVERHEAVY MAUSAFYLE3 IN PLACL ROM LEACKNELD RUNBACK OXCUSIVE SOLID -SOLTDCARRYO YZR� QTKEREXPLAI'N �ybtvm RWT"i WMMENTS. f KA NsYbY.Ut) 1-(,, I J, - TOWN PF, NO&,TH ANDOVER SYSTt7M PUMPTN(3 RECORD l DATE SYSTEM OWNER & ADDRESS SYSTEM LOCATION DATE OF PUMPIN4- .0'22 QUANTITY'PUMPED Ll!::�G D CESSPOOL NO S,_� SEPTIC TANK NO YES NATURE OF SERVICB;,.RQC�'I'INE ' EMERGENCY OBSERVATIONS; GOOD CONDITION FULL -TO COVER . OOT�S GREASE _,; BAFFLES IN LACE LEACHFIELD RUNBACK EXCESSIVE SOLIDS _T'FLOODED SOLID CARRYOVERS OTHER EXPLAIN SYSTEM PUMPED BY 4111. COMMENTS; � }, �` y,i1 1rt L � 17r! i .r_I•Y r .��F( ��'� . .� r1 ' r Ll orb NORTH 'ANDOVDR.,.�' SYSTEM PUM*pr.�Q RECORD ;i�,�T`i,i LLA { SYSTCm LOCATION (MMI),IC IC11 frons of hou r) TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: E: SI'STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) �I DATE OF PUMPING: QUANTITY PUMPEDC�GALLO:NS C1 -'S S 1) 0 0 L: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE _EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: C'ONIMENTS: C:ONTEN"I'S TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) ` : 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD , 4 DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION j.• -- .-:r� �Sdn (example: le 4 front of house) ro DATE OF PUMPING:"• / QUANTITY PUMPEDDD ..L GALLONS CESSPOOL: NO YES ZSEPTICANK: NO YES""NATURE OF SERVICE: ROUTINE ERGENCY w r PBSERV_ ATIONS: GOOD CONDITION, FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ' ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS _ FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) 0 a tr,t SYSTEM PUMPED BY: �b v k" l}i{ ➢+ ..fy'.� yeti Ni ]• � ,�. 1 d 4. '...,,' !'. ,. — , i1¢1CQMMENTS: , ai i f,u�JGQNENTS TRANSFERRED TO: William F. Weld Goamor Trudy Coxe Seeretuy, EDEA David B. Struhs Comminioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protectior �j 6-0 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFI TION 2 0 �" in2w►P�1e ��-\, ` , P Property Address: Address of Owner: Date of Inspection: �, 2,� 9 6 (If�different) Name of Inspector: Ott PlY k � Company Name, Address and Tele hone Num er: J� D -e/2 Tele �- c ,, 1-/2 k�,/ 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XPasses Conditionally Passes Needs Further Evaluation By the local Approving Authority Fails Inspector's Si ature: Date:� �] The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty (30) days of completing thiis inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] YSTEM PASSES: 1 A__ I have not found any information which indicates that the system vi_olates•an Zfltlle allure trite ii Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: rOne or more system components nee%tc1b,eflreplacedxw-wpai__ The system, upon completion passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or e imminent. The system will pass inspection if the existing septic tank is replaced with a t approved by the Board of Health. (revised 8/15/95) 1 -- I( One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • 0 Printed on Recycled Paper as defined in 310 CMR 15.303. the-repia©ement or repair, ined", explain why not) m, or tank failure is ing septic tank as Telephone (617) 292-5500 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a ft, % -e Owner: Date of Inspection:',`C B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system nas a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Dj SYSTEM FAILS: N, 4. 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /� CERTIFICATION (continued) ,! /� Property Address: Q �e� �� e l / � A" " lI'v® V Owner: Date of Inspection: D] SYSTEM FAILS (continued): 1-1114. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS:/ f r The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a 0 J �°� 141, �loll -�f �t /i floor d (!,4,1 t� Owner: Date of Inspection: Check if thefoil ing have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. built plans have been obtained and examined. Note if they are not available with N/A. e facility or dwelling was inspected for signs of sewage back-up. _YT_system does not receive non -sanitary or industrial waste flow he site was inspected for signs of breakout. f4N system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or /ees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ;__1 size and location of the Soil Absorption System on the site has been determined based on existing information or roximated by non -intrusive methods.he facility o,,%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 1,, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: U C� c' l�/O v Owner: V Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: Qallons Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no):�5 Laundry connected to system (yes or no):`L5 Seasonal use (yes or no): Yd t." N Water meter readings, if available: % Last date of occupancy: W M t -Q tom. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: '4/a GENERAL INFORMATION PUMPING RECORDS and source of information: -� /e 11 S /Fe System pumped as part of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping: TYPE SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: J` Sewage odors detected when arriving at the site: (yes or no) —yo (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Q C-0 Ayr h -c /% IA/ Af-1106 " '0" Owner.: (� Date of Inspection:/j A- o SEPTIC TANK:(D S (locate on site pl n) �f Depth below grader Material of construction: _`concrete _metal _FRP —other(explain) Dimensions: Sludge depth: =,r Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: /r Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: IV r Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) r G /V P q CC Q'/- G ('Z/t k GREASE TRAP:_ P 4L (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of Brum t- bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8%15/95) 6 c? ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ;-o n1 be/j�- Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: , 7 Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:�� (locate on site plan) Depth of liquid level above outlet invert:�I Comments: (note if level and distributic^ equa!, evidence of so!id� carn-over, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) Property Address: Owner: Date of Inspection: � G 5' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (c tinued) SOIL ABSORPTION SYSTEM (SAS):P S (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ fey �� leaching galleries, number: leaching trenches, number,length: !/" > leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (locate on site plan) 0 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) , Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) Y L � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: '1_0 ra fi(�I �< </ 00 Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 51 t QP(Z- r� DEPTH TO GROUNDWATER Depth to groundwater: 5- '4fet method of determination or approximation: (j'- 04 t (1 b0 A-1 (revised 8/15/95) 9 r APPLICATION FOR SEWAGE DISPOSAL INSTALLATION o/0-50- HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at . 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 29o. I will install a con- crete septic tank of ,; o o o 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 lineal kequare) 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 I ZRt �J✓ Signat f Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE —�Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. jC DATE Signature of specting Office , Percolation Test j- 2'..�' dlaul'OA4.9 Garbage Grinder 2jd__ BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. t A L in Alp 1. NAME ` IA i �-� . I I .. , ,.7 DATE 2. ADDRESS y� 1 � �i LOT NO. TEL. 3. NO. OF BEDROOMS DEN YESy _ 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 H. 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. v-ILv> Z106-4 J BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE May 27, 1967 NAME OF APPLICANT Phillip S. Sullivan LOCATION Lot #13, Campbell Road Address of lot no. BUILDING: Dwelling x Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND High SUBSOIL: Clay x Gravel_ Sand PERCOLATION TEST 5 minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 11000 gallon capacity. LEACH FIELD 180 lineal feet of drain pipe. Liz z)zWilliam J. D scoll, Engin r Board of Hea h li l p y `� Donohoe, John ".�....««. Lot 13, Campbell Ed. I APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER MASS. I hereby make application for a permit for a sewage disposal installation at Lot 13, Campbell Rd- . 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 _ 1000 0a1, 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 200 lineal (UMI) 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 Iof 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 I atttaachto the permit. Plot Plans must be submitted with application. DATE n Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover,ssachus s. 'V& — && DATE / - / G - L. 5 �-mow.--- /Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer Percolation Test 6 miji. Sandy -Clay Garbage Grinder No rl e, BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. W 0i C9'Y�d�C l �p u 1. NAME f� DATE 2. ADDRESS & C--// j LOT NO. �''"�— TEL. ' 3. NO.,OF BEDROOMS 1,3 DEN YES NO x 4. GARBAGE GRINDER YES NO X 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 Ajoril 22, .1956 NAME OF APPLICANT John DonDhoe LOCATION Lot #13, Campbell Road Address of lot no. BUILDING: SYSTEM: Dwelling X Other New X Repair GENERAL DESCRIPTION OF LAND High SUBSOIL: Clay Gravel Sand Z_ajay X PERCOLATION TEST b minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1000 gallon capacity. LEACH FIELD 200 lineal feet of drain pipe. -1 ), t -,O -d illiam J. D scoll, Engi eer Board of Hea h Commonwealth of MassachusettsI�l�� City/Town of North Andover a System Pumping Record SEP i 2�1t Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1 forms on the computer, use only the tab key to move your cursor - do not use the return City/Town key. 2 Sys em Owner: ,� r Name Address (if different from location) City/Town N.Andover Ma 01845 State State Telephone Number Zip Code Zip Code B. Pumping Record &. I (ez— 1. Date of Pumping � 2. Quantity Pumped: 1 C� Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. ,System Pumped -Naftf Stewart's Septic Service Company 7. Location where contents were disposed: Ste�va�t'S Pre-treatment,Plant, 20 So. Mill Bradfoi If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 /Si jhatL re of auler D / Signature oz F ` t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Y ip ron ro �- G � 9 � tri 0 r� • — — tai � C ro -D L S/1 n H OM CA (A G x LTJ S 'y O r + z ro �r OMH t2j °z Vf Y1 U �r- ip ron ro �- G � 9 � tri 0 tzj til Z tzi � C ro -D L S/1 n H vci CA (A G x LTJ S , ip ron ro � z M tri 0 tzi � ro n H vci CA (A G x H O r + z ro �r OMH t2j °z U �r- 1 , n CA O p H 0 � H O z •�