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HomeMy WebLinkAboutMiscellaneous - 208 SUMMER STREET 4/30/2018 (2)Q N Wco PO cn Q m 0 O d T) O 1 r Lot & Street al Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid:YES NO Pere- tm Plan Approval: Date: 9 Approved by: Designer: —Plan Date. - Conditions, Water Supply Town . Well Permit: N0 YES NO YES NO Well Tests: Chemical; Bacteria I Bacteria H Plumbing.Sign-Off: Comments: Form "V' Approval: Date Issued Conditions - _ Well. -.Driller: Date Approved Date -Approved Date Approved __. -Wiring Sign -Off - Approval to By— Final Approval: All Permits Paid? Well Construction Approval? Septic System Construction Approval? Certification? Other Any Variance Needed? FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: YES NO YES NO YES N0 YES NO YES NO YES NO YES NO SEPTIC SYSTEM INSTALLATION Is the installer licensed? YES NO Type of Construction: SEW _ gEpAIR New Construction: Certified Plot Plan Review YES NO —Floor Plan Review YES NO - _ Conditions of Approval from Form U YES NO _Issuance of DWC permit: - YES NO -.DWC Permit Paid? -- YES NO . --DWC-Permit # L1 Installer: �J? e-/& BegihJnspection:_ _ _;_�:.�. NO _Excavation Inspection: —Needed - Passed: - - By: ..._Construction Inspection: Needed: I_- - Approval of Backfill.- ---Final ackfill:---Final Grading Approval Date: ,/ ,� By: Date: `�/� By. _ Final Construction Approval: Date:: -`-f B Certificate of Compliance: Approval: dr SEPTIC SYSTEM INSTALLATION Is the installer licensed? YES NO Type of Construction: SEW _ gEpAIR New Construction: Certified Plot Plan Review YES NO —Floor Plan Review YES NO - _ Conditions of Approval from Form U YES NO _Issuance of DWC permit: - YES NO -.DWC Permit Paid? -- YES NO . --DWC-Permit # L1 Installer: �J? e-/& BegihJnspection:_ _ _;_�:.�. NO _Excavation Inspection: —Needed - Passed: - - By: ..._Construction Inspection: Needed: I_- - Approval of Backfill.- ---Final ackfill:---Final Grading Approval Date: ,/ ,� By: Date: `�/� By. _ Final Construction Approval: Date:: -`-f B Certificate of Compliance: Approval: Commonwealth of Massachusetts City/Town of . System Pumping Record Form 4 DEP has provided this form for use -.by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of houseLL ri ide of u , sLeft / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address city/Town State Trp Code 2. System Owner. Name Address (if different from location) Citylrown State de Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: - ❑ 4. 5. ❑ Other (describe): Date 2. Quantity Pumped: Gauons Cesspool(s) Septic Tank ❑ Tight Tank Effluent Tee Filter present? ❑ Yep No Condibo, j f System:�0 ! If yes, was it cleaned? ❑ Yes ❑ No. 6. System Pumped By: v Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location a contents were disposed: I- 3•j,1 _ Lowell Waste W. RECEIVED DEC 21.3,,-,,2013 TOWN OF NORTH ANOOVEIR !JI^A! Tu nrT+x Sign Haul Date t5fomi4.doc• 06/03 System Pumping Record • Page 1 of 1 Town of North Andover NORT f 1 OFFICE OF 3� O E� µ e o �O L COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street �o �" ; North Andover, Massachusetts 01845X94 4AT 5 P WILLIAM J. SCOTT SO fSAcHus� Director (978)688-9531 Fax(978)688-9542 a April 8, 1999 Bill Dufresne Merrimack Engineering Services 66 Park Street Andover, MA 01810 Re: 208 Summer Street L` ? No. Andover, MA 61 -8 -45 --- Dear Mr. Dufresne, This is to inform you that the proposed septic system plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/eoh cc: Karl Born File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 12/29/99 This is to certify that the individual subsurface disposal system constructed ( ) or repaired ( X ) by Mike Reilly at 208 Summer Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 1064 dated 4/6/99. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. `.t Board of Health Inspector AS -BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/N 1 50' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE 1/ DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. (/ NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BEING: USED LOCUS PLA- MORTIS s 6054 - � 9 b i • Town of North Andover HEALTH DEPARTMENT ,SSACNUSt� S�\/ CHECK #: DATE: LOCATION: �� H/O NAME: • •%fRVAI/ Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Tit Inspector $ C3� Title 5 Report $� ❑ Other: (Indicate) $ i Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Cort monwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address Matthew R. Cummin Owner's Name North Andover City/Town MA 01845 March 31, 2012 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the'end of the form. A. General Information 1. Inspector: Peter F. Reilly Name of Inspector Peter F. Reillv Company Name 136 Andover Street Company Address Andover APR 19 NQ vnwm nF NORTH ANDOVER HiAI.TH DEPARTMENT MA 01810 City/Town State 978-375-3750 S11955 Telephone Number B. Certification License Number Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature March 31, 2012 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ r� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address Matthew R. Cummings Owner's Name North Andover MA 01845 March 31, 2012 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. A. General Information 1. Inspector: Peter F. Reilly Name of Inspector Peter F. Reilly Company Name 136 Andover Street Company Address Andover City/Town 978-375-3750 M State S11955 Telephone Number License Number B. Certification EIVED/ /� 4",�_ OR °I MN -Of NORTH ANDOVE# HEALTH DEPARTMENT 01810 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 her Evaluation by the Local Approving Authority March 31, 2012 In p or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 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 208 Summer Street Property Address Matthew R. Cummings Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 State Zip Code March 31, 2012 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: Z 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. El -1 Y ® N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 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 208 Summer Street Property Address Matthew R. Cummings Owner's Name North Andover MA 01845 March 31, 2012 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address Matthew R. Cummings Owner Owner's Name information is required for. North Andover MA 01845 March 31, 2012 every page. Cityrrown 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 '/2 day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address Matthew R. Cummings Owner Owner's Name information is required for North Andover MA 01845 March 31 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s m 208 Summer Street Owner information is required for every page. Property Address Matthew R. Cummings Owner's Name North Andover City/Town C. Checklist MA 01845 State Zip Code March 31, 2012 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ .® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 gpd t5ins • 11110 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 208 Summer Street Property Address Matthew R. Cummings Owner. Owner's Name information is required for North Andover MA 01845 March 31 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1,500 gallon septic tank / d -box / SAS (field). Replacement system installed in 1999. Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gpd)): 250 gpd avg. Detail: Sump pump? ® Yes ❑ No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address, Matthew R. Cummi Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: March 31, 2012 Date of Inspection currently occupied Date BOH (last pumped 6/4/2007) gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Owner information is required for every page. Property Address Matthew R. Cummi Owner's Name North Andover City/Town D. System Information (cont.) State 01845 March 31, 2012 Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: replacement system installed in 1999. Were sewage odors detected when arriving at the site? ❑ Yes ® No 10" - 12" feet N/A V WVV ysuc ion ne. feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer was watertight and appeared sound at the foundation. Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron [-]40 PVC El other (explain): Distance from rivate water s- I well or C Ii Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal am feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 6' x 12' Sludge depth: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Owner information is required for every page. t5ins • 11/10 Property Address Matthew R. Cummings Owner's Name North Andover City/Town D. System Information (cont.) State Zip Code March 31, 2012 Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 4"-5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was watertight and appears to be functioning properly. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 0' 208 Summer Street Owner information is required for every page. Property Address Matthew R. Cummin Owner's Name North Andover MA 01845 March 31, 2012 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: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 208 Summer Street Property Address Matthew R. Cumm Owner's Name North Andover Cityfrown D. System Information (cont.) MA n1 Rdr, JLGIC LIP lruuC Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert M1 March 31, 2012 Date of Inspection 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.): Four lines leading to SAS were accepting effluent fairly evenly. Some solids carryover evident. The box cover was about 21" below the surface. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address Matthew R. Cummings Owner Owner's Name information is required for North Andover MA 01845 March 31 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 1 - 25'x 36' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils in the area of the SAS appeared normal, no signs of breakout. SAS dimensions based on information from 1999 "as -built" plan on file at BOH. It is noted that the system is 12 years old and observations made at the time of inspection provide no indication as to how the system will perform in the future. 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts N w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address Matthew R. Cummings Owner Owner's Name information is required for North Andover MA 01845 March 31 2012 every page. City/Town 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 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 208 Summer Street Property Address Matthew R. Cumm Owner's Name North Andover MA 01845 March 31, 2012 City/Town 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D - SYSTEM INFORMATION (continued) Property Address: 208 Summer Street, North Andover, MA Owner's Name: Matthew R. Cummings Date of Inspection: 3/31/2012 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. N/A Locate where public water supply enters the building. � r 1 SEPTIC TANK TIES: A to Inlet 14.3' B to Inlet 26.8' A to Center 13.5' B to Center 30.6' A to Outlet 13.6' +1 t D -BOX TIES: A to Box 20.8' C to Box 56.0' NOTE: The system is [a � r 1 SEPTIC TANK TIES: A to Inlet 14.3' B to Inlet 26.8' A to Center 13.5' B to Center 30.6' A to Outlet 13.6' B to Outlet 34.0' D -BOX TIES: A to Box 20.8' C to Box 56.0' NOTE: The system is in the left front yard. The water service is marked on the sketch. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street Property Address Matthew R. Cummings Owner's Name North Andover MA 01845 March 31, 2012 City/Town 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: 4' below bottom of SAS 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: 1999 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: information on file. ® Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USGS data not specific to site. You must describe how you established the high ground water elevation: 1999 design plan indicates separation of 4' at that time. However, the precise ground water elevation cannot be determined for certain without a soil evaluation test. NOTE: Soil evaulation is the recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaulator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified septic system inspector. (see attached Discliamer) Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Summer Street G,,M Sye y`ev Property Address Matthew R. Cummings Owner Owner's Name information is required for North Andover MA 01845 March 31, 2012 every page. Cityrrown 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based. on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. P er F. Reilly Inspector March 31, 2012 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The ` ndersigned hereby certify that the Sewage Disposal System ( ) constructed; ( 7epaired: by located at ,76P 4jt �.j Id E& was installed in conformance with the North Andover Board of Health approved plan, System Design Permit #J& dated_�/(, I q g with an approved design flow of,41V gallons per day. The mate 'as 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: Engineer Representative Final inspection date: Engineer Representative Installer:—Lic.#: Date: Design Engineer: eftcA.,_ Date:. M 0 2 E o` LL ull 0 r U rz Un ro � J L LLL O U - c Q Q L O Q Z m w 0 MW LU CL Z _O U ce I— V) Z 0 Y 3 J Q O n V) W 11 Iv, H w MG w ' n c 0 Q in LL 0 Q ;.f r'n LL APPLICATION FOR DISPOSAL WORDS CONSTRUCTION PERMIT DATE: 113a_a � CU-RR.ENT INSTALLER'S LICENSE# LICENSED INSTALLER: SIGNATURE: �` TELEPHONEA Lf'��� CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Admanistrative.Use Only 575.00 Fee Attached? Yes 1'1� No Foundation As -Built? Yes No Floor Plans? Yes No Approval��j J Date: off( SEP 2 2, 1993 Town of North Andover, Massachusetts Form No. a f NORTq BOARD OF HEALTH O't.o 1,SO 0 w p # y DESIGN APPROVAL FOR SSACH SEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant--f�jZL-0.�'� Test No. Site Location o'Z6�3 �50MmG'01 6 Reference Plans and Specs.%[—PRIAOC ��UF Stiff �. ENGINEER DESIGN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIRMAN, BOARD OF HEALTH Site System Permit No. /Q6/4*-' Town of North Andover OFFICE OF COMMUNTTY DEVELOPMENT AND SERVICES 27 Charles Street WILLIAM J. SCOTT North Andover, Massachusetts 01845 Director (978)688-9531 April 8, 1999 Bill Dufresne Merrimack Engineering Services 66 Park Street Andover, MA 01810 Re: 208 Summer Street No. Andover, MA 01845 Dear Mr. Dufresne, Fax (978) 688-9542 This is to inform you that the proposed septic system plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/eoh cc: Karl Born File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF F- ORTHH ANDOVER/ BOARD OF HEALTH MAR I SOIL EVALUATOR FORhl Page 1 Commonwealth of Massachusetts Massachusetts PerformedBy:........ �✓ 6a ........ ............. ............. _.... ............................ Witnessed By:..... � �_:...�::�:.'":":�::..............._�.._......._................::�.............:::............................................................:"�. New Construction ❑ Repair o,,%Nate. TekpMe f /pfd' -G l/5l s Published Soil Survey Available: No Yes Year Published ...q/ Publication Scale ..syyo Soil Map Unit ....... DrainageClass .......�,.�" Soil Limitations................................................................ .............. .......... .... Surfici g Pal Geologic Report Available: No Yes ❑ Year Published Publication Scale ............•...•. GeologicMaterial (Map Unit) ....................................................... ........ ................................................... Landform Flood Insurance Rate Map: Above 600 year flood boundary No ❑ Yes Within 600 year flood boundary No L.7 Yes ❑ Within 100 year flood boundaryNo Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) .................. ............................................... _............................................. Wetlands Conservancy Program Map (map unit) ................................................................. Current Water Resource Conditions (USGS): Month Range : Above Normal ❑ Normal ❑ Below Normal ❑ Other References Reviewed: 1,L'56S- AD i�� DORM 11 - SOIL EVALUATOR FORM Page Z Ort -site Review Weather... Deep Hole Number ..._._ Date: �Y % Time:.....101�� � -�-- Location (identify on site plant -..__ ...:........._..................-.....-....................... _.... --..w.. Lend Use - s ' -r �...__._ _. _. Slope (961 n?r Surface Stones ... .......-....-�vegetation . �� �' ...-.._ ?ll�....�%!c�,..._ v _..._......__ ............. 5.......... _......... _.._............... -................. -_- ..... -_--... - ......__ Landform ...........dr..__ ..__... _... _........ .... .................. _............... ...................... ................ _- ._.-...._....-_ position on landscape (sketch on the back) �µ-...:._.........__._..........._.-...-_....__...-.._-___.........�.._. Oistenos . a from: Open Water Body feet Drainage way -k feet, t Possible Wet Area feet Property Line 4°"K. K. feet Drinking WaterWeII7i rf�-_r- • feet Other •••••••••.••••.. ........................ I Depth lb►atNhom 6urfAw al / u 608 , moa $ LVl\ i�.4►�a:r a.v•.• � 6s608 f�0ta1n0 ISwcc 1 aYki 2.5Y Yv Gv (w. (-, s. 4 1 Z 5-rWY Parent Material 198010910).G�-.................................... -................. .............. Depth to Bedrock: Depth to Groundwater: Standing Water in the Hole: ��•••• • Weeping from Pit Face: p Estimated Seasonal High Ground Water:.... .... . . • Ir FORM 11 - SOIL EVALUATOR FORM page Z Ori -site Review Deep Hole Number r' Date: l� Time:.�k..� Weather _...................._.................._....._......................... ' _..___.'� Location (identify on elle glen( •.••�-.--��•i� •"�� • • •••• Land Use Slope 1961 Surface Stones Vegetation_ ._.,cc/ kR2•---_._.._....._._................. _.._._..._............. _.............. ,...................... _................................... _..... .___..._.......__ Landform.......... _.._..fuAal......_.................._...__............ .............. _...... ___........ __......._.... _._............ _ position on landscape (sketch on the back) -.............•••............................... --- _ �- Distances from: ' Open Water Body 2-�W feet Drainage way t feet, Possible Wet Area l feet Property Line ._:�fP � feet Drinking Water Well feet Other .......................................... 0 [►ePth from Surface SoII Horton SM Taxtura 6" Color SoN MAt"IQ 8oublar�, Ilnaheal WSDA) IlJlIMMI) C fenny. 15=11 Parent Material 1peologicl.._ h al....._.................................................................... Depth to Bedrock: D ath to Groundwater Standing Water in the Hole: y°' Weeping from Pit Face: l Estimated Seasonal High Ground Water:.. �W O s A 1v 3� G= r. 7,YYX6 Y 4,/3 Parent Material 1peologicl.._ h al....._.................................................................... Depth to Bedrock: D ath to Groundwater Standing Water in the Hole: y°' Weeping from Pit Face: l Estimated Seasonal High Ground Water:.. �W c- a FORM it - SOIL EVALUATOR FORM Page 3 ❑ Depth observed standing in observation hole ................. inches ❑ epth weeping from side of observation hole .........•....•.. inches Depth to soil mottles _.. `. Inches 1�el-wl 2-d ❑ Ground water adjustment ............ feet Reading. Date ....__....._.... Index well level Index Well Number 0. ------ Adjustment factor Adjusted ground water level .....�� _..._�� ..._..� .._.....� .__.• Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? DxV If not, what is the depth of naturally occurring pervious material? - C8022110 I certify that on (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 16.017. Date Signatur FORM 12 - PERCOLATION TEST COMMONWEALTH 'OF MASSACHUSETTS _ Massachusetts Site Passed Site Failed ❑ Performed By: ___ z:z J. o Witnessed By: G comments: ........................................................... Percolation Test • �.�vlr� Date: .�........ Time.._ Observation Hole #t Depth of Parc `- start Pre-soak End Pre-soak 2 , Time at. 12. Time at 9" l Time a�t 6" o l Time l90-601 �© Rate Min./inch Site Passed Site Failed ❑ Performed By: ___ z:z J. o Witnessed By: G comments: ........................................................... j-/99 131 1.-.- Town of North Andover, Massachusetts Form No. 1 NORTH A BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Applicant_ /"s/ ACG -k-UZAJ NAME ADDRESS TELEPHONE Site Location_ ° +0 MA &Z :5,7- Engineer 5f"'Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time M14kC14 8, /9Q2 AQ 3 CHAIRMAN, BOARD OF HEALTH Fee -07,5— Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH , %�Oe�SED 6�ti�L 19 o PLhAA AP -TION FOR SITE TESTING/INSPECTION \- ATED Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Board of Health '`North ndoverj%ws Y SUBSURFACE DISPOSAL DESIGN CHECK LIST ' l LOT' APPROPED DATB__j L& -� q lV5_1 DISAPPftOPED DATE oviAeids Reasons: RkVj5C+) ?COrVS . [ _ �'Z�' Uel G1f 15 PPE 4 (AJC . Title V I FAIL I IK Reg 2.5 Reg 6 The submitted plan must show as a minimums 'a) the lot to be served -area, dimensions lot #abutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations, calculations showing required leaching area e) location and dimeasf.ons of system -including reserve area f) existing and proposed contours ,g) location any wet areas Within 100' of sewage disposal system or disclaimer -check Wetlands mapping h) surface and subsurface drains Within 1001 of sewage disposal system or disclaimer ,`i) location any drainage easements within 1.001 of sewage disposal system or disclaimer -Planning Board files J) known sources of Water supply Within 200' of sewage disposal e system or disclaimer k) location of art proposed well to serve lot -1001 from leaching facilii location of Water lines on property _ 10' from leaching facility location of benchmark 'iveways -- - garbage- disposals �f) PVC-t6lbe used An construction profile• of system -elevations of basements plmnb�_ pipe, septic tank, - -- _ distributioa- box: 'inlets- and ou - ete,, distribution field =Piping -and _= �- Otker elevations r)- maid a -ground -water --elevation in - ar sewage --disposal system plan' mast be prepar;Wby a JFr-ofessio - -- Raginser =or_ other - _ - professional'authorized by law to prepare such plans - Septic Tanks 'a) canacit es- 50% of flow, water -table, tees, depth of. tees, I" access, p,.Uping b) cleanout n) 101 from cellar v -all or inground siumaing pool - - d) 251 from subsurface drains Reg 10.2 I Distribution Boxes a) slope greater than 0.08 Reg 10.4 b) suap iI ubsurce Design Check List _Page 2. r `eg 11.2 11.4 11-10 . eg 15.1 15.4 --3;7_ FAIL - . - �. OK - Leaching Pits _ T " _. _ ^.^ ! .,.a .., ...� 1. . .. ...y !r ^ ^a^,+... .a ... � ^ —n.p. 'yam^ .. p .o .. J. .9 •- h A .. -R ... —y .. ! 1. A ... ^ a) calculations of leaching area-� 500 sq ft -- --- b) spacing c) surface drainage 2% d) cover material - -- e) IIx2 tarn" splash pad f tee at elboiz a) no '-'cnds in pipe from d-;xx to pipe -- --` - � Leachingfields - - Ia) no greater t 20 minutes/inch ) area -minimum 900 aq ft c construction of field , surface drainage 2 M^ e)-24j=fhonr-cellar-=-o and --sem i - - r=te g ==beachin �enchss a) cal . ons_ o leaching -area min--500-sq b) spacing-l� ft min 6- ft with reserve between' _ - d) constriction a atone i f� surface drainage 2% Downhill 31 e a) supe y x = to be shown) b) y/x x 150 - (to be shown) i Pumps a)approve-- - b) stand-by power - - .,.. i _ - - — -- _= = = _ eg llt.i 14.3 14.10 = ag 9.1 9.6 - v - M North • Andover,, Nass. Street No T,o c/Subd.iv. PI and- . . Investigator _ J Observer SOIL PROFILE DATES „1_lev 2.Elev 3.Elev 4 �• -__Lot No Ovmer 1, —1 4. El ev 0 — 0 0 — 0- — 'Pips. to Test Pits --- �. 2 - 2 2 - -- tD'27 5 ---- 5 — ---- �`----- - -- - - — 10 _ -- --- — 10 - -- -- - i o - --- - - — Bench -mark 7,�c iion Elevation Datum-____-- PR-RCOT,ATION - - --- - '-'r STS DATES -- - - (v� --- -------------- - - — Start Saturation -- - - ---�-- ---- --�;&0 u4V- ---- _ Jir oz 3' T�_1ae ----------- ----- --------- ------- Drop of 6" Time -- -- --- ------ ---- TM'c n s .1- s t 3" °-onDr p -- — -- —------- ----- - -�— - - -- ---- 14 r W da 4 ? "r• r W da Board `of Reslth North AnSiov _Kana. SEPTIC SISTA " INSTAILATICK CHECK LISP LOT'I95T APPROVED' DATE M SUTRUM AVATI Ui Og WL L y Rea`sons� ts• . n per, r�,.� . _ _ - .. , � FM OK Dis ance Tot i . a. Tetlands b !rains 2. Water. Line Location ' 3.' No PPC Pipe •fir - '_ 4. Septic Tank a.,, -Tees -_Length do To iClean Out Covers. b. Cement Pipe to Tank'- Cn Both Sides of Tank 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Equal Amounts ' C. No Back Flow 6.- Le. ch "field or Trench a. Oix :rasions b. hone Depth c. 'apped Ends ' d. ^lean Double Washed Stone 7. Leah Pits a& pensions r b. 'tone Depth C.' Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides ' f. Clean Double Washed Stone - -:-• 8. No Garbage Disposal 9. Final Gr ading Inspection l0. Barricading Covered System . As. Built Submitted a. Lot Location :, Dimensions of System c. Lor-�tion' with RegarcLto Pere Test d. El orations e: Water,•Table IJ 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 PHONE L, -L LOCATION: Assessor's Map Number (y'3 0 PARCEL 1-71 SUBDIVISION LOT (S) STREET ST. NUMBER RECOMNE19DATIONS OF,T CONSnVATION ADMINI$TRATO COMMENTS I TOWN PLANNER COMMENTS USE ONLY*************** AGENTS: DATE APPROVED DATE- REJECTED DATEAPPROVED DATE REJECTED - FOOD INSPEC R -HEALTH DATE APPROVED DATE REJECTED 7;74:�2� '§EfTIC?�SFtCTdR-HEALTH DATE APPROVED DATE REJECTED COMMENT PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT 1/0 FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE SLOPF 96:1QUI)FEUENT (/50) X = /50 = 3Q DES/CSN EC E!/.47 -ION ,4T 30 ' (TOP OF STONE) = 213. T 61- FI1.4T/ONS DE.51(!�N 45 BU/LT INV P/PE OUT OF HOUSE 214;09 11VV P/PE INTO T4NK /NV P/PE OUT OF TANK 213,42 213 . C� 1/VV. PIPE INTO D. BOX /NV P/PE OUT OF D. BOX 213 -) � 2 ► 3.4 3 /NV ENO OF P/PE 213 , o0 2.; 141ZTE2 ELEtl,4TION 2o�-coo 2aE> c,o ,4 VEZ46E 5 TONE DEPT11 4T 14'1C'O3E U NOTE. T11/S PL,IN /5 NOT ,4 W4,P2.4NTY OF TIVE 5Y5TEM BUT ,4 !/E2/F/C,4T/ON OF T/1E GOC.4TION OF 7WE EX/STIM� 5TeUCTU2E5. En�sF- 11F NT as aur r , SUB-SU.ZFGCE D/SPOS. SYSTEM /N NOf i l � ,41v pe FOR C'!IE/STIANSEN ENS/NF�,e/NC, /IIIc. //4 AIENOZ.4 .4 !/E.� &4VE�Pl11L L, IYU... I L o T 2-,,k 43,594 S.F. /t/ U , EASEMENT 5LOPF 2600//FEUENT (-150) X = 150 _ o DESAON EC EV4T/ON AT 30 (TOP 12F STONE) 'I 6L,Fv.4T/ON.5 - DES14�/V 4.5 BUILT" /NV P/PE OUT 0,F/1&1,5E 214 o'f /NV P/PE INTO T4NI 2 13. (.-7 INV. PAPE OUT OF T,4NK 21342- 213 INV PIPE INTO D. BOX 213,3610 ?-1 .4 5 INV PIPE OUT OF D. BOX INV END OF PIPE 2-13, oo Li WW TE2 EL EV,4 T/ON b . 00 2 o ,4 VER,40E STONE DEPTH ,47 REOBE IVOTE.- T11/S PI -4N /S NOT ,4 W,4,e1?,4NTY OF THE SYSTEM BUT ,4 !/E2/F/C,4T/ON Of T#E LOCATION OF T,VE EX/5T/MC ,el Tn„/+T„� rC ,45 BU/LT SUB-SU�PF,4CE D/S)POSdL SYSTEM IN FOR 5"LE.- I 40 � DATE: JZ17. 4, AMS5 C�,e/5T/QNSEN ENCIME INC, /NC. //4 f<ENOZ.4 .41/E., A4VE,Pl//L L, AU. Lc-) T 2 A g-1,594 S.F. SLOPE' 2600//FEUENT (/50) X = /50 5 = O DES/6N E1-EVdT/ON ,4T 30 (TOP /?F 57ONE) =2,1;.57 6Z&Y..4T/ONS DE54�N 441.5 BUILT IN/. P/PE OUT OF, -/OUSE 214 . o INE! P/PE INTO T4NK 2 /NV PAPE OUT OF TANK 2 1 3 , 4Z 11V,V PIPE INTO D BOX 213,3(- F-1-5,45 //VV P/PE OUT OF D. BOX 2 3.)9 2 3.4 3 /NV. END OF PIPE 213.00 2I 3.4 5 Gi/4TE2 ELEI/,4T/O/1� 2oe.00 2o&.00 AVE2,40E STONE DEPfTf/ AT' eQ,5E 1.0 ' 1, 0 NOTE: T11/S 101-,4N 45 /VDT ,4 l .4,1e41VTY OF TA/Lc SYSTEM BUT ,4 VE2/F/C,47-ION OF T11E LOCATION OF T/IE EX13TIN6 ST2UCTU2ES. P, 0 t&o�- -I m ' AsE r1I NT fps%' _s OF Maw_ SIS BV/LT SUB— S111RF,4CE D/SPOS�lL SYSTEM Na�rH /NANDo vER F02 Forza E- t eEq z- -r TR . SCALE: l _ 4O OgTE: JZ/'7. �{, 885 G�/,e/ST/4NSEN ENG/NEEP/NC,, /NC. //4 KENOZQ .411E, f/.4YE.Pf//L L, MA. Tir '6WM OF tqO R�'H AiYDO'VER SYSTEM PUkPING UCOR.13 > l"57'1; M OWNER & ADDRESS SYS7'Ei`LOCA't'10' CUt1f (exAmple: left iron, of house) DATE OF PUMPIMC:, QUANTITY PUMPCl316�fGALI0�� �:aSNUUL: N YES __ K; NO SEPTIC TAN YES NATURE OF SERVICE; ROUTINE EMERGENCY (MSE RVATION& " GOOD CONDITIOI+t FULL TO COvEit HEAVY GREASE IIAFFLLS IN PLACE. --- ROOTS LEACHFIELD RUMBACK- "CLSSI-VE SOLIDS FLOODED" SOLIDS CAMIYOVER--pjj'H?R (EXPLAM) S I -STEM PUM PED D Y: (.•U.V1 M f NTS: c UNTENTS TRA NSPSItRED TO: :r i i tAlsiWWn11+a;�,';!.,'177. f;IYrJ'�rK' � ('l�''{r'.S`:^''•i' 1 'h,lirJYt•.U.' ,; , DER hail rovided is' p, ,form for use by local Boards of Haalth_ e �ubml#ed to th4,loca11'Board i •r• uf:•i' All i•Y ,Jti:yt{n•'v,{r;r t:":•:nw'• .A Facility matlon When'tilWi "out ;1r System Location;` MY ttte tab to mow yol. Vii' •a::'?t�'( '�' •'!!' J: .,, �.,''j • Nme r 'Y ti+Yt ♦ , {p, 1 r .. ..., • .t. Sr:r ..r. r,, .;.i,;;. '. ����r/ / /lam .. ""', -�°i Addreu (If different from bcatlon) ' :1 i. :Ia.••..� (''' State' 9R 0 0 • ;• • _ ;r�r •�� t ! `'•� Telephone Number J B Put>>.pi g.Regord, It tl �' Ir`'�i'�1tt�i6}f(:rJ;W�Q{Ib(isA�G/YSf�!rG;l. �y{,:• / ur '. ; � 1. �' (t �-�. nir 1 J. j;\lF , ,r ,•, /� r L °�•' ' ;: OatpV Pumping' , antit t oa • 2. Quy Pumped: % S Gallons ;3r: '.Type Pf ayatem ; ❑Cesspo'ol(s) eptIc Tank ❑Tight Tank . °r' ;�(�.LOther (describej;•'° •. , • �• 1��:�r^!..i�::,'Ct';:,{.;''i',i:,J'tr,.'.'•rJl;:.;�`r.:r''': '•7;:v..: ,: "'.' '' .. ' t Y � (f::'j'7 '.(!+�,,, '••; r ✓;i, i,..��:;rz•p,��',i iYl?'�r'r' •:PJM 'i ; .. `�'r" • Tea Fllte(present? ❑Yes, EIKo It yes, was It cleaned? Yes-97No es ',��_ .�( �. �,�.�i: '•., .,'ri,,.nrr rW�r/„{'•.r:!":• ,f:rt r.l4ju'.�(r.l'. r,.'; 'J ,A, . olidl�lon of8ya[i[i•.�A]m; . .. .. ..t..,. .7!tiw.y�,: •• `. �J!r +'Ir�1%pt�r ►,R,-L,•M1n ib�,tlrq. rl,,n J«•n rr, r,'•,., ., - ' .r r•, 7i\•.' �y • J i" t Y+ ,4 �r Fi,'li':yf,, (. t >;, ,,,•'.rr.,;, ,, f .. ti.. a'.. {.<•t 1 t rsSi•)r,��'�.'r, 'J,,.l. y� �}r �'1�.'r1`, J; r.:• .�i. "'��;' ,r�.,• L ',,awe ,.'l. 'it'�FL4 r r i .;:. ..., :,a';;J='r!:•'yiivT.,;jYt,.:`�'�t'.;r+.Start+•�'(�1%�iy'tt,:} r.�: • f Q .h , J �jr Sy 8Z7i1� Pumped By: " ?�,f� ,: ,•;,•..yy.i:�;; � "'lir G .. • •'Jif ,': i'i:,'.•:�•i ,, . ��.� {�"�,:�. :::,',fvamar,�s;i! t;, •,:,�'� ;;,;;:,;' vehicleUCB N ..+. _ .. .. ........ cd <"... .. _ _ rar)'. ,,!.!i�•U� f•.4 r...✓t ••riot .air. ..�• t�ti'' r'1• r•Jf `;4i.:4 ! � i}�r ',V • :'• '.;r." : a. 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Professional Engineers & Land Surveyors 160 Summer St. Haverhill, MA 01830 (978) 373-0310 FAX (97.8) 372-3960 TO: � V 5-1w 19-: AtJo LIVr 13d' lleK //--Z" FA Ise. 01 Srd- 6,1 Z :� k /nn..® c T Ir4ce_ regaY- C Please reply. DATE:7/� /q� SUBJECT: 1104 M 4>^ SSSS 1elpu )r �kdeld?rTe n i/v A'9 J7 d-fjL ,,..,. 6Y- Z4r'lqCe- f dw'e /a A, z z , -7—,s % ?,:7 SIGNED �No reply necessary. "�,' y