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HomeMy WebLinkAboutMiscellaneous - 21 DEER MEADOW ROAD 4/30/2018W Commonwealth Of Massachusetts _ - CifyyTTown ®f North Andover System Pumping Record Form 4 your DEP has provided this form for use by local Boards of Health. Other forms may be used, but the chk with information must be substantially the same as that provided here. Before using th d must be submitted o local Board of Health to determine the form they use. The System Pumping Recothe local Board of Health or other approving authority within 14 days from the pumping, date in accordance with 310 CMR 15.351. _K_Informat�®n important When filling out forms 1. System Location: yy� on the computer, 1 )�eer I �' l e use only the tab gja—��� key to move your Address Ma 01886 cursor - do not North Andover Zip Code use the retum State C'r<,j/rown key. 2. System Owner: �cd a Name FQ ti rman Address (if different from location) State Zip Code City/Town B. Pumping Record 3. Date of Pumping Telephone Number 1560 - 2. Quantity Pumped: Gallons Date Type of system: ❑ Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumpe4,6y ❑ Tight Tank ❑ Grease Trap .If.yes,-was it cleaned? ❑ Yes ❑ No 15" _ c P 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 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Pag Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 w ` knCEIVD, AUG'I C 2013 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. A. Facility Information 1. System Location: Left / Right front of house, Left / ht rear of hous. Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Rig rear of building, Under deck Address City/Town'1�-- 2. System Owner. Name Address (if different from location) State Zip Code Citylrown State r7 Z!*p C/o0e Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date 2. Quantity Pumped: Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? E] Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No ."euA V1ew 6. System Pumjped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. L contents were disposed: GLLS.R _ Lowell Waste Water u1eq I Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Deermeadow Property Address David Mount Owner's Name North Andover Cityrrown MA 01845 State Zip Code 8/8/2013 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 >er�n City/rown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C 8/8/2013 Inspector's Signatu 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Deermeadow Property Address David Mount Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 State Zip Code 8/8/2013 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new septic tank, outlet pipe to d -box, new d -box, inspection from B.O.H., septic system now passes Title 5 Inspection. 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 -Deermeadow Property Address David Mount Owner information is required for every page. Owner's Name North Andover MA 01845 8/8/2013 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 a Of NORTH , V Z) Z) 1 !a 10 _ 9 Town of North Andover S" ;; HEALTH DEPARTMENT CHU CHECK #: 15�) S DATE: I I LOCATION: �'�.rn,r,ri G� CONTRACTOR NAME: �Ck 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 Sys: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title S Inspector $_i,,� �✓ , XTitle 5 Report X ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI ISI 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: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI 15 Telephone Number B. Certification License Number 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 ❑ Needsurther E aluation by the Local Approving Authority //j, U 7/16/2013 inspk&s Agnature V 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 RECE!l ED Commonwealth of Massachusetts Title 5 Official Inspection Form JUL 2 2 2013 o Subsurface Sewage Disposal System Form - Not for Voluntary Assess t VN OF NORTH ANDOVER HEALTH DEPARTMENT 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. City/Town State Zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI ISI 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: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI 15 Telephone Number B. Certification License Number 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 ❑ Needsurther E aluation by the Local Approving Authority //j, U 7/16/2013 inspk&s Agnature V 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 .15 -. 41 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Ndt for Voluntary Assessments 21 Deer Meadow Road Property Address David Mount Owner's Name North Andover MA 01845 7/16/2013 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND (Explain below): Liquid level in septic tank was 2" below outlet invert t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. 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 obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ® N ® N ® N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ❑ obstruction is removed ❑ Y ® N ❑ or obstructed pipe(s). The ND (Explain below): 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 21 Deer Meadow Road Property Address David Mount Owners Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 7/16/2013 Date of Inspection 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: Septic tank is leaking out, pipe from tank to d -box is collapsed & d -box needs to be replaced. 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 '/z day flow t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover every page. Cityrrown MA 01845 7/16/2013 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. Citylrown State Zip Code Date of Inspection C. Checklist 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 been determined based on: this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not approximation of distance is unacceptable) [310 CMR 15.302(5)] 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): t5ins - 3113 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 ..� 21 Deer Meadow Road D. System Information Description: 7/16/2013 Date of Inspection Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information Description: 7/16/2013 Date of Inspection Water meter readings, if available: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Yes 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "t 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. CitylTown 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: Date Date of Inspection Pumped March 2012, owner 1500 gallons Measured tank Inspect tank & outlet tee - Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ® Yes ❑ No ❑ 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Deer Meadow Road t5ins • 3/13 D. System Information (cont.) 7/16/2013 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 33 vears old. 7/10/1980. as built Dlan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): ❑ Yes ® No 2 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall. 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 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: 10'x5'x4' Sludge depth: 3" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code t5ins • 3/13 D. System Information (cont.) 7/16/2013 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 33 vears old. 7/10/1980. as built Dlan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): ❑ Yes ® No 2 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall. 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 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: 10'x5'x4' Sludge depth: 3" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 23" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Outlet baffle ok. Outlet tee ok. Depth of liquid 2" below outlet invert, evidence of tank leaking out. Outlet pipe to d -box collapsed. 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: t5ins • 3113 Date Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts DA Title 5 Official Inspection Form (I uv� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. Cityfrown 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 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Deer Meadow Road Property Address David Mount Owner's Name North Andover MA 01845 7/16/2013 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box cover broken & d -box filled with sand. No liquid in d -box.. 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: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 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 21 Deer Meadow Road Property Address David Mount Owner's Name North Andover City/Town D. System Information (cont.) Type: State 01845 Zip Code 7/16/2013 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 46' ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. 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 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21 Deer Meadow Road Property Address David Mount Owner information is required for every page. Owner's Name North Andover Cityrrown State 01845 Zip Code 7/16/2013 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 • 3113 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 21 Deer Meadow Road Property Address David Mount Owners Name North Andover MA 01845 7/16/2013 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately Davd�'�rdl& W 13 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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: 5/28/1980 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts 'EM low Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Deer Meadow Road Property Address David Mount Owner Owner's Name information is required for North Andover MA 01845 7/16/2013 every page. City/Town State Zip Code E. Report Completeness Checklist Date of Inspection ® 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 Summary Record Card generated on 6/2612013 2:50:22 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-104.6-0071-0000.0 Parcel Id 16394 21 DEER MEADOW ROAD MOUNT, DAVID 21 DEER MEADOW ROAD N. ANDOVER, MA 01845 Class 101 Single Family Zoning2 1 Residential Size Total 1.02 Acres FY 2013 Property Type Zoning3 1 Residential 1 Residential UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MOUNT, DAVID Payor 21 DEER MEADOW ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18119.0 - 21 DEER MEADOW ROAD Last Billing Date 4/10/2013 3180147 03 Cycle 03 Active UB Services Maint. Account No. 3180147 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 45.60 /1 UB Meter Maintenance Account No. 3180147 Serial No Status Location Brand Type Size YTD Cons 13242184 a Active 00 METE METE w Water 0.63 0.63 380 Date Reading Code Consumption Posted Date Variance 6/14/2013 788 a Actual 28 163% 3/20/2013 760 a Actual 12 4/22/2013 -12% 12/13/2012 748 a Actual 12 1/9/2013 -77% 9/19/2012 736 a Actual 56 10/15/2012 442% 6/18/2012 680 a Actual 10 7/16/2012 -7% 3/20/2012 670 a Actual 11 4/14/2012 25% 12/19/2011 659 a Actual 9 1/17/2012 -78% 9/16/2011 650 a Actual 41 10/13/2011 104% 6/13/2011 609 a Actual 19 7/20/2011 90% 3/15/2011 590 a Actual 10 4/13/2011 43% 12/15/2010 580 a Actual 7 1/12/2011 -89% 9/16/2010 573 a Actual 64 10/15/2010 150% 6/14/2010 509 a Actual 24 7/15/2010 156% 3/18/2010 485 a Actual 10 4/14/2010 -14% 12/14/2009 475 a Actual 11 1/12/2010 -33% 9/16/2009 464 a Actual 18 10/15/2009 40% 6/10/2009 446 a Actual 11 7/20/2009 11% 3/18/2009 435 a Actual 11 4/29/2009 35% 12/15/2008 424 a Actual 8 1/20/2009 -59% 9/15/2008 416 a Actual 21 10/10/2008 27% 6/10/2008 395 a Actual 15 7/16/2008 36% 3/14/2008 380 a Actual 11 4/11/2008 -10% 12/17/2007 369 a Actual 13 1122/2008 -71% 9/14/2007 356 a Actual 40 10/12/2007 154% 6/21/2007 316 a Actual 18 7/20/2007 245% 3/16/2007 298 a Actual 5 4/16/2007 -43% 12/13/2006 293 a Actual 8 1/19/2007 -77% 9/19/2006 285 a Actual 37 10/20/2006 167% 6/20/2006 248 a Actual 14 7/10/2006 -3% L t5form4.doc• 06/03 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, Lefttif ear of house, ft /right side of house, Left / Right side of building, Left / Right front of building,Rightrear o uilding, Under deck Address City/Town State Zip Code 2. System Owner. y� Name Address (if different from location) City/town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ btate 6 / r r tZ ip Code Telephone Number (K, Date 2. Quantity Pumped: Cesspool(s)* R-9eptic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 314 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of stemi� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loca ' r�e contents were disposed: G.LS-Q _ Lowell Waste Water F5821 Vehicle License Number r? ,�� �C Date System Pumping Record • Page 1 of 1 V - 0 NOR3`�Lo SSA C�HUs� PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/9/2013 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of Tank/D-Box/Pipe By:Todd Bateson At: 21 Deer Meadow Road Map 104B Lot 0071 North Andover, MA 01845 The Issu ce of this certif ate shall not be construed as a guarantee that the system will function satisfactorily. S/V/Sa Sawyer -Pub is Hea �ent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 21 Deer Meadow Rd. MAP: 104B LOT: 0071 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: I Tank/D-box/Pipe DATE OF BED BOTTOM INSPECTION: 8/8/13 DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK 1 �✓ D fl L � N� ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered 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 Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port 5J Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER H Bottom of tank hole has 6" stone base ❑ Weep hole plugged 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ \Alarm tank construction ❑ stalled, centered under access port ❑ nstalled on stable base ❑ t working ❑ Off floats working F-1Separate N 1off floats ❑ Drain hole in\Salgrade ❑ covernstalled over pump access port ❑ Watertightn been achieved by tes❑ Hydraulic celet &outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: LOCATION: H/O NAME CONTRACT 6559 Type of Permit or License: (Check box) cf Nor+tti �y ❑ F A Town of North Andover `�'••;; :o :: HEALTH DEPARTMENT CHECK #: 1 ! DATE: I LOCATION: H/O NAME CONTRACT 6559 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 $ "XISeptic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ (8 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer I Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _Q Application for Septic Disposal System Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 l3 TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component 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 system_ epair or replace an existing system component - What? A. Facility Information -- � 1 �R �'i.����� Vim_- d����:.►!�:~.� Address or Lot # Cityrrown 2.- *TYPE OF SEPT HEALTH SYSTEM*: SRN C� NCEPARTM RTH ANDOVER T R ➢ ❑ Pump ravity (choose one) ***If pump sy attach copy of electrical permit to application*** ➢ YConventional System (pipe and stone system) ➢ ❑ Infiltrator or Biddiffuser (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 �r If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? "at is the Model. 2. Owner Information Name Address (if different from above) City/Town State Zip Code �g'%7 Telephone Number 3. Installer Information �,f f-esd� Name Name of ComTIAM 1l � TON � •��� , RNN � ENTERPRISES, INC. Address fANDOVER, MA 01810 City/Town State Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Inforination Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 t Application for Septic Disposal System Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building:Residential Dwelling or ❑Commercial B. Agreement TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Ith, the installed system is not approved. Name Date Application Approved By: (Board of Health Representative) Name Application Disapproved for the following reasons: Date For Office Use Only: L Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No I Pump S sy tem? If so, Attach copv ofElectrical Permit Yes No 4. Reviewed approval letter, all paperwork received. Yes No Missing: 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 SEP"I'IC SYS'�'EM.INS�A L.ER'PROIEC."T MA�t�GEMEN'�' �BLIG�iTION. As the North Andover licensed installer for the construction for:the septic system for.the property at (Address o septic system) ^ For plana by Relative to the.appEcation of I; -A6 (ia'staIlees name) Atid dated Dated ( With reviuot o a s ae I understand the following obligations for management of -this project: 1. As the installer, I am .obligated to obtain. all permits and Board of Health approved plans: to performing any'work on a site; I must have the Vbroved glans and the hermit: on site when any work is Ring done 2. As the ing4er;.I,must.-call, -for any and all'inspt'cdbns: If homeowner, contractor, .project mauager, or any other person not associated with m' company schedules -an inspection and the system is not ready, then item three shall, bri applicable. .`' As'tliC lusta�ltr, I ou itq#cd to. have .t'he necessary work•co ngleted,prio* to the opplicable in�pectioos as indicated beim, T'ri�tdeittan that r��ctin�•`��n Mi speed n,;Z.-Jo, t completion of the items in accoidanci Betloli cif 3ed.: tneraily, this is the ftrs:X.�.1'�:`ir�'speotiom unless. there is a retaining wall, which shou`lc�•be drine< rst: The nstall niusttcgotst #lit itispecd(5A but sloes. riot have to be ptesent. . b. Fina - etlori.I eetiori —Eng neer mvs_•t- 6i, , thes;r its ection for elevations; •tim -etc. As-bdilt of verbal OK'(or e-mail'to: r. from the engineer must be submitted to .t1ie.Board of Health, aftex:wliiChanstalier.ca3ls for -an iasp'ectipn time. 'Installer must be present for fl*.inspection, With.apump system, all electrical wotk:must;be ready and able to cause;putrap't6-v+ orkacid!alaun:tofunetion.. C. Fin ' `Gtade installer must request inspection �vheii'Il grading is' compltte:..Installer'does not have to be ,.on=site. 4. As -the installer,' I understand that only 1 miperform the vork' (othtr than : mplt excavation) and •I am required to complete the installation of the systen idendfipd in flit. attached application' for installation: I urth'e reasons for dei ialoion of•my lieense•to 0=94 -in -the Town of 'North Andover. si iuficant fines .gyp all jy ale. 5.. At the.instiller, I understand that'.I tntisl eon=side during t4.perfi imance .of the following construction steps: a: Det atioei that.th'c ptioper efevatron ofthe areaeation has been reached. A Inspection ofthe sand and stove'to be used, ' c. Final inspection by BomW ofHedth staff or consufwnt d Installation. 6f tank Doxf pipes, stone, vent, pump chamber, retar�ing waUanol other . components. 6. Undersigned Ilceasepdc.Ia$ 1.let: (Today's )Ate) ZS R Commonwealth of Massachusetts City/Town of System Pumping RecordFr �R Form 4 TOWN LT R D PARTMENT DEP has provided this form for use by local Boards of Health. Other fo a 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 (I giht rear of hous Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address + a� City/Town State Zip Code 2. System Owner. MLVC+ Name Address (if different from location) Cityrrown Statg�� 4—`� dip Code Telephone Number a B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: �z IeVA 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location w ere contents were disposed: S. Lowell Waste Water n� Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No tVu F5821 Vehicle License Number -arra Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 a L o -- -1 2,4 f PIEFRM-'TADOW Lt,��r F, OUT QFNSE ► ►.+v � vFF roti v i 6 4, 9 � \/ .4 1 Jy 4 `/ /y fo 3?r 46 bulL-T cJ VE5_5UI,F" r' i nit 5Y�aT IN r<•r F 24 tit K- G G E t_i ,p�5 I A c, S C)C NE: r=. �' S � Ai2L.4-t ITEC T S g St .4N Board of Health North An ver Haas. OK n oC SISM INSTALLATICK CHBCK LIST 1111, IIW111' •1:11 tOlOil I1;Y�-9 3/#10 1. Distance Tot a. Wetlands b. Drains c. Well i 2. Water Line Location 3. No PPC Pipe %. Septic Tank - a. - -Tess --Length & To Clean Oat Covers. b. Cement Pipe to Tank Oa Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal. Amounts c. No Back Flow 6.. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped ids d. Clean Double Washed Stone 7. Leach Pits a. Dimensio s b/Clean Stone epth Pads dePipe to Pit - Both Sides. fDouble Washed Stone 8. No Garbage Disposal /9.-ginal, heading Inspection 10. Barricading Covered System 11. As Built Submitted. a. hot Location'- .--- b. Dimensions of System C. Location Kith Regard_to Perc Test d. Elevations e: Water Table ;3 r ,. Al / ri- - North 1nd:• . ?r, `•^ a APPRC VED DAZE 7 „�� T/ Providedi V� SM,_'V�q8 D SO:'' . `S3 5lCz t CFLCK Lt, DISAPPRUM DATE�,� Reasons s ,f�c I-- kI //�I , -: �;#. /)6 ", 1) Title V Reg 2.5 Reg 6 Reg 10.2 Reg 10.4 FAIL CK -- - - -- - - --- ---- - ---- - The submitted plan must show as a minimum: 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 shoring required leaching area e) location and dimensions of system -including reserve area f) existing and proposed contours= g) location any vzA areas tithin 1001 of sevrage disposal system or disclaimer -check w3tlaods mapping h) surface and subsurface drains within 1001 of sewage disposal systema or di.sclairar (i) location any dr ainae patsy"w"its Within 1001 of sf age disposal system or disrla!jr: r-Mmv�i ng Board files J) know sources of tater svgpl.y within 200' of Liovzge disposal system or disclaimer location of aw proposed well to serge lot -1001 from leaching facility location of water Lines on property -10' from lei hing facility Flocation of benchmark n) driveways o garbage disposals no PVC to be used in construction q) profile of system- elevation a of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field pigging and bt4ler elevations r) raxinum ground -eater elevation in area sc-;:age disposal system s plan roast be prespared by a Professional. Engineer or other professional aut *rized by law to prepare such plans Septic Tanks a) capac t ee-1a0% of flog, later table, tees, depth of tees, access, pining ) cleanout lot Brom cellar mll or inground sulmring pool (d) �5f from subsurface drains Distribution Boxes a) slope greater than 0.08 (b) orap FAIL I Oil Lam. Pits t Leaching pits jarQ preferred where the installation is possible a) calculatio s of leaching arca-minir 500 sq ft b) spacing c) surfa drainage 2% d) cov material e) 21 ' 411 splash pad f) a at elbow g) no bends in pipe from d -box to pipe Leaching Fields A) nogreater 20 mutes/inch b) area -minimus goo sq ft P) construction of field d) surface drainage 2 % e) 201 from cellar mll or inground ooirZdng pool Leaching ,aches nsoeach3ng area -min 500 sq ft ft min 6 ft with reserve beta*an c el/sx*ae f ssrfaae drainage 2% mKrill Slop e a) s e y x -- oto be shown) b) y/x x 150 - (to be shoran) LUM S a) approval b) stand-by power SOIL PROFILE & PERCOLATION TEST DATA i,or',Uh Andover ,I:3ss. No.&Stree Lot No.� Loc./Subdiv. -4- Plan - Owner Investigator Observer .-717 SOIL PROFILES -DATE 1' _ 2. Elev. 3' Elev. --'Elev. — Elev. 0 0 0 0 s 1 1 1 1 t Ties to Test Pits 2 2 2 2 3 3 3 4 4 4 - 4 5 5 5 5 - r 6 6 6 t 7 7 7 7 8 8 g 9 9 _ 9 _ 9 10 10 10 10 Benchmark Location I Elevation Datum Percolation Tests -Date Pit Number l 2 3 4 5 Start Saturation Soak -Mins. Start Test -Time — Drop of 3"-Tirne Drop of 6" -Tine I, ir•s. 1st 3"Drop I;ins . 2nd 3"Drop f Notes & Sketches on Back SOIL PROFILE & PERCOLATION TEST DATA North Andover J:ass. No. &Street Lot No. ) j' Loc./Subdiv. Plan Owner Investi-gator `: Observer SOIL PROFILES -DATE 1' Elev. ?' _ Elev.— 3' Elev. 4'Elev. 0 0 _ 0 0 _ 2 2 _ 2 2 Ties to Test Fits 3 3 3 3 ----- 4 4 4 4 S S 5 5 6 6 6 6 7 7 7 7 8 8 8 8 I9 _ 9 9 9 10 10 10 10 Benchmark Elevation Location Datum Percolation Tests -Date Pit Number 1 2 3 4 5 Start Saturation � Soak -Mins. Start Test -Time Drop of 311 -Time - "-Time-Dro Drop of 6" -Time Mins.lst.3"Dro Mins.2nd 3"Dro Percolation Rate Rotes & Sketchee on Back ► ELEyo.-r i aN'5. 7 FRA+v�C � N M A 5 E5 u i L. -r cJ V py - S U >- IrAc.. D I S POSAL-- SYST EM IN F o c2 SG4LE I" =�p DAT 19%6 F 2.6. t -A C G 0 EL► tai 4�S �— A ,!E> .TES t= NC�tNEE>25 � At2G�-11TEGTS Board of H80-th North Ano-ver3Haes. APPROVED DATh easonsi OK BEmc SisTEK INSTALLATICH CHmK LIST LOT 1, Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PPC Pipe it. Septic Tank a.. _Teas -_Length & To Clean Out Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks unts b. All Lines Flowing Equal c. No Back Flow 6.. Leach Field or Trench a. Dimensions b. Stone Depth c: Capped lads d. Clean Double Washed Stone 7. Le7PJ_pe a*ons b.epth c.Pads d. Pit _ Both sides g. tooubYe Washed Stone 8. No Garbage Msposal 9. Anal Grading Inspection 10. Barricading Covered System 11. As Built Submitted-. a. Lot Location'. b. Dimensions of System C. Location _4th Regard_to Perc Test d. Elevations e; Water Table VA k Board,of Health North AndovergMass SUBSURFACE DISPOSAL DESIGN CHECK LIST ., LOT_ APPROVED DATE�.�� Providedi DISAPPROVED DATES Reasons: Titl V FAIL OIC ., Reg .5 The submitted plan mist show as a rdmimumt a) the lot to be served-area,dimensions lot #,abutters location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties design calculations & calculations showing required leaching area location and dimensions of system -including reserve area existing and proposed contours (g) location any wet areas uithia 100' of sewage disposal system or L/ 114 ✓ disclaimer -check Wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements Within 100' of sewage disposal system,or disclaimer -Planning Board Piles knows sources of water supply within 2001 of sewage disposal ; system or disclaimer (k) location of a�r;proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -101 from leaching facility m) location of benchmark -n) driveways o garbage disposals (p no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and ✓ ®then elevations (f) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities -150% of flow, water table, tees, depth of tees, access, pumping (�) cleanout Kc) 10t from cellar wall or inground swimming pool 25+ from subsurface drains V -71(d) Reg 10.2Distribution Boxes a) �gr greater n 0.08 Reg 10.4L:::.Ab) m P, FAIL Reg 11.2 11.4 11.10 11.11 a Reg 15.1 15.4 15.8 t 3.7 Reg 14.1 14.3 14.4 14.6 14.7 1h.10 Reg 9.1 9.6 Check List UM I �A Leaching Pits Leaching /pits are preferred where the installation is possible calculations of leaching area-mdn4mum 500 eq ft spacing surface drainage 2% I over material 2,42 1 x4n splash pad ,tee at elbow no bends in pipe from d -box to pipe Leaching Fields nogreater than 20 minutes/inch area -minimum 900 eq ft construction of field surface drainage 2 % 201 from cellar wall or inground swin d.ng pool c 2' Leachin Trenches calcu .alops leaching area -min 500 sq ft spacing-:! �t min 6 ft with reserve between f) surface drainage 2% DowahiA Slone a} s ope y x ='kto be shown) b) *7isd7a /150 = (to be shown) a) b} by power SOIL PROFILE & PERCOLATION TEST DATA, North Andover,I�ass. Nn.&Street Lot No.� Loc./Subdiv. Plan Owner InvestigatorObserver ?n,9_41r� . 1 6 SOIL PROFILES -DATE 1. Elev. 2. Elev. 3. Elev. 4`Elev. 0 0 0 0 1 1 1 1 Ties to Test Fits .. 2 3 4 5 6 7 8 9 i 10 1 2 3 4 5 6 7 8' 9 10 3 2 3 4 5 6 7 8 9 10 5 2 3 4 5 6 7 : 8 9 10 Soak -Mins. Start Test -Time-: -_.___---_--- #___:.. - -- -- - _.- Dro' of 3" -Time "' Dro of 6" -Time 2 - Benchmark_ Elevation Location Datum Percolation Tests -Date Pit Number 1 .2- 3 4 5 Start Saturation Soak -Mins. Start Test -Time-: -_.___---_--- #___:.. - -- -- - _.- Dro' of 3" -Time Dro of 6" -Time 2 'ins. lst . 3"Dro Mins.2nd 311Dro pt - Percolation Rate Notes & Matches on Bask BOARD OF HFA"LTH North Andover, Massachusetts APPLICATION FM PERI''ItT TO KEEP ANIMALS AND BIRDS IN NO.ANDWER DATE To the Board of Health: The undersigned hereby applies for a permit to "KESP CEiTAIN ANIMALS AND BIRDS" z'3thin the To:•n of North Andover, in accordance with Chapter III, Section 31 and 10 of the General Laws., and subject to the rules and regulations of the Board of Health. KL -id of Animals Location Total. Acreage Date received Date approved Permit No. No. ;ind of Birds Sigr•,: ure of Applicant Address Approved by: St. ��� �A} J {,4 � l �l'1 �_ # � ��j' _� ` �� System Owner 00 jV 'T Commonwealth of Massachusetts Massachusetts System Pumping Record System Location 21 be F2 m Lrr�o�,j J_) O v E -g_ 04A SJ Date of Pumping: Quantity Pumped: t j 00 gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes, System Pumped by: 64ad" sieeo%ed" License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: