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HomeMy WebLinkAboutMiscellaneous - 2189 TURNPIKE STREET 4/30/2018 (2)r, O N O co Oo 1 n � Z rn m c m O m O m I. 1 N t't � Commonwealth of Massachusetts Title 5 Official Inspection Form "polo,Va k- Not for Voluntary Assessments �3 Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification RECEI EM Important: When filling out 1. Property Information: 0 C T 13 2006 forms on the computer, use 2189 Turnpike Rd N Andover only the tab key Property Address I I UVVN OF NOR;-H ANDOVER to move your II Woong Koo HEALTH UEi'ART^,�L NT cursor - do not Owner's Name use the return key. 2189 Turnpike Rd Owner's Address N. Andover MA. 01845 Citylrown State Zip Code Date of Inspection: Date 6 Date 2. Inspector: N . Timothy White Name of Inspector Homepro North shore Company Name PO BOX 101 Company Address ROWLEY Ma. 01969 Citylrown Zip Code 1-978-948-8428 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority /11 , 1 '1.� $, 9-30-06 Inspector'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. Shortcut to TITLE V.lnk.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 16 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form M A. Certification (cont.) 2189 Turnpike Rd Property Address N. Andover Ma City/Town II Woong Koo Owner's Name State 9-30-06 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 01845 Zip Code ® 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: na Shortcut to TITLE V.lnk.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Not for Voluntary Assessments M yVOr Subsurface Sewage Disposal System Form A. Certification (cont.) 2189 Turnpike Rd Property Address N. Andover Citylrown II Woong Koo Owner's Name B) System Conditionally Passes (cont.): Ma State 9-30-06 Form Date of Inspection 01845 Zip Code ❑ 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 ND Explain: na ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: n 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 Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 2189 Turnpike Rd Property Address N. Andover CityfTown II Woong Koo Owner's Name Ma State 9-30-06 Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 01845 Zip Code 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: zj ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 2189 Turnpike Rd Property Address N. Andover Cityrrown II Woong Koo Owner's Name Ma 01845 State ZipCode 9-30-06 Date of Inspection 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 ❑ ® 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments 5.0r ` Subsurface Sewage Disposal System Form A. Certification (cont.) 2189 Turnpike Rd Property Address N. Andover Ma. City/Town State II Woong Koo 9-30-06 Owner's Name Date of Inspection 01845 Zip Code 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. Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Checklist 2189 Turnpike Rd Property Address N. Andover City/Town II Woong Koo Owner's Name Ma State 9-30-06 Date of Inspection 01845 Zip Code 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(3)(b)] Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments yySubsurface Sewage Disposal System Form C. System Information 2189 Turnpike Rd Property Address N. Andover Ma 01845 City/Town State Zip Code II Woong Koo 9-30-06 Owner's Name Date of Inspection 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): 110 = 440 gpd Number of current residents: 4 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 9 ( Y 9 (gpd)): well Sump pump? ❑ Yes ® No Last date of occupancy: still occupied 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? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): Shortcut to TITLE V.Ink.doc • 11/2004 ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2189 Turnpike Rd Property Address N. Andover Ma City/Town State II Woong Koo 9-30-06 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 01845 Zip Code last pumped 2 years Information from owner gallons ❑ Yes ® No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 13 years old information from owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 2189 Turnpike Rd Property Address N. Andover Ma. 01845 CitylTown State Zip Code II Woong Koo 9-30-06 Owner's Name Date of Inspection Building Sewer (locate on site plan): Depth below grade: 7 in feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 27ft from incoming water line to outgoing sewer line in basement Comments (on condition of joints, venting, evidence of leakage, etc.): Joints & venting good condition no evidence of leakage Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 12 in feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 10 ft long - 5ft deep 5ft wide 1500 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 2in 30 in 2in 6in 15in rulers - measuring rod Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2189 Turnpike Rd Property Address N. Andover Ma 01845 City/Town State Zip Code II Woong Koo 9-30-06 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was not pumped - inlet Baffle &- outlet tee in good condition - liquid at bottom of outlet invert - tank appears to be in good condition no sign of leakage in or out of tank Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ® metal rte. ��-L /C'C' CP Dimensions: Scum thickness ❑ fiberglass 61 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle feet ❑ polyethylene ❑ other (explain): — _ � )c;d L', Lo Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 2189 Turnpike Rd Property Address N, Andover Cityrrown II Woong Koo Owner's Name Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Ma 01845 State Zip Code 9-30-06 Date of Inspection gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): NA 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 was level - distribution was equal - no evidence of any solids carryover - no sign of leakage in or out of d -box d- box was 28in below qrade - size was 17x17 in inside depth 13in Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: Shortcut to TITLE V.Ink.doc • 11/2004 ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2189 Turnpike Rd Property Address N. Andover Ma 01845 City/Town State Zip Code II Woong Koo 9-30-06 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): na Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches number: number: number: number, length: 4 Trenches - 55ft long each ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): dry gravel sand soil - no hydraulic failure - no ponding - system was in front lawn - Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form M yver C. System Information (cont.) 2189 Turnpike Rd Property Address N. Andover City/Town II Woong Koo Ma State 9-30-06 01845 Zip Code Owner's Name Date of Inspection 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): na Privy (locate on site plan): Materials of construction: Dimensions NA Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2189 Turnpike Rd Property Address N. Andover Ma. 01845 Cityrrown State Zip Code 11 Woong Koo 9-30-06 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 � Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,ySubsurface Sewage Disposal System Form C. System Information (cont.) 2189 Turnpike Rd Property Address N. Andover Citylrown II Woong Koo Owner's Name Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Ma. State 9-30-06 Date of Inspection Please indicate all methods used to determine the high ground water elevation: 111 Obtained from system design plans on record If checked, date of design plan reviewed: Date 01845 Zip Code Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: from past title 5 inspection shows ground water at 4ft from orignal grade system is raised Shortcut to TITLE V.Ink.doc ° 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 NEW ENGLAND ENGINEERING SERVICES INC E D04l"?GIVERrE T October 1, 2004 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: RE: 2189 Turnpike Street, North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely 0 �/ Benj C O Jr. J g Certified Title 5 ' spector 60 BEECHWOOD DRIVE -.NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: l 811 Owner's Name: g p-,4 p k," t Owner's Address: -z sq - T1, ,Iv; pr ii, e IV o MHN o aj e2 AA 4 Date of Inspection• _ } 10 y Name of Inspector. (please print) Benjamin C. Osgood, Jr. Company Name: New England Engineering Services Inc. MaGing Address: 60 Beechwood Drive, North Andover. MA 01845 Telephone Number. 978-686-1768 Receive OCT 5 2004 "OWN 'A O N DEPTH ANDO,,,, �`rn�E,vr CERTIFICATION STATEMENT I certify that I have personally inspected the sewage. disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant toSection15.340 of Title 5 (310 CMR 15.000). The system: -:�.L res Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: v Date: O rV The system inspector shall submit a copy of this inspect a report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of 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. . Page 2 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: A t c3 G TV `e P 14 e Sp A- J i-) oy c <— Owner: 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 1 .303 a 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 descx''bed in the "Conditional Pass" section need to be replaced or repai<ed. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following .statements. If "not determined" please explain. Theseptic 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. ND explain: Observation of sewage backup or break out or high static water level in the distributionbox 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 ND explain: t The system required pumping more than 4 times a year due to broken or obstructed pipc(s). The system will. pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Pagel .of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: v2 t P q P C3 i it f fs-- Do, et - Owner: .Date of Inspection: C. Further Evaluation is Required by the Board of Health: ,AL Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to prded public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protea public health, safety and the environment: _ Cesspool or privy is within 50 fed of a surface.water _ Cesspool or privy is within 50 fed of a bordering vegetated wetland or a salt marsh ...:Z- 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 coliforpi bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ;Z1 I a q 7'u (Z vA Pi }� 10 A.,-� 7 o ue,-f- ,A - Owner: 0 2A -It-;> V� , 4 A 2c0 Date of Inspection: --- 2 D. System Failure Criteria applicable to all systems: You mast indicate "yes" or "no" to each of the following for all inspections: Yes No BadaiP 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 Yz day flow — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. — ✓ Any portion of cesspool or privy is within 100 fed 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. of a cesspool or privy is within 50 fed of a private. water supply well. . �Anyportioa Any portion of a cesspool or privy is less than 100 feet but greater than 50 fed from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (YeslNo) Thesystem 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. You must in either `yes" or `5no" to each of the following: (The following crit ply to large systems in addition to the criteria above) yes no — _the system is within 400 fed o a ce drinking water supply _ the system is within 200 feet of a tributary to a ace dripldni'water supply — the system is located in a nitro e�,se�sitive`a (Interim i�ellhead Protection Area - IWPA) or a mapped Zone II ofra pub}ic-wat�-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. s Page 5 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _,�Z 18 q i u jL vi pj K F NI -1R it F A4 �-! V Owner: 1�,le- &0 #9-rz0 Date of Inspection: �o y Check if the following have been done. You must indicate `des" 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 hVected for signs of sewage back up ? Was the site inspected for signs of break out ? — Were all system components, excluding the SAS, low on site ? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition Of the baffies 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 Sail Absorption System (SA.S) on the site has been determined based ow. Yes/no EE' ung information. For example, a plan at the Board of Health. Determined is ►/ � ed the field ('if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 13 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: t ger T`, R v, p i SL_(_ _— )iZ �l i Ate? Al N - Owner• Date of Inspection: o r� FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x # of bedrooms): Number of current residents:^ Does residence have a garbage gander (yes or no): AID Is laundry on a separate sewage system (yes or no): N [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): ALD Water meter readings, if available (last 2 years usage (gpd)): t)j a L_ L Sump pump (j= or no): -ALO Last date of occ fancy:-- COMMERCIAL/INDUSTRIAL Type of establishment; Design flow (based on 310 CMR 15.203) - Basis of design flow (seats/persons/sq%etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): , Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: bTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no): At If yes, volume pumped: Gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool — Privy — Shared systm (yes or no) (if yes, attach previous inspection records, if any) _ Innovative(Alte mative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _Tight tank _ Attach a copy of the DEP approval _ Other (describe): Approximate age of all components, date installed (if known) and source of information - 0 -5--f rypre 0 `✓L,Q As 6u,— Were sewage odors detected when arriving at the site (yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 t Pq -rL) p_vi j2, tLc 77 Owner; i2 9-A-9 w A L > Date of Inspection: Z� o BUILDING SEWER (locate on site plan) Depth below grade:_ Materials of construction: cast iron IZ40 PVC other (explain): Distance from private water supply well or suction line: IS Comments (on condition of joints, venting, evidence of leakage, etc.): f i P L L-c�o j4_5 Y1 C vJ' t Ay 9 t1s tit eE A V SEPTIC TANK: _ (locate on site plan) Depth below grade:1 Z " Material of construction: _concrete metal fiberglass _polyethylene If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: (5cso(,-_,���� N Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness; 2 - Distance Distance from top of scum to top of outlet tee or baffle: 6 " Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:- Comments etermined:Comments (on pumping recommendations, inlet and outlet tee or bade condition, structural integrity, liquid levels as related.to outlet invert, evidence of leakage, etc.): 3�vt� K 1 iv K is 9cl-I dry l a r ce GREASE TRAPAbIllocate on site plan) Depth below grade: _ Material of construction: concrete metal fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: i u it o Owner. - .� P -M-0 w y �" Date of Inspection: a 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/day Alarm present (yes or no): Alarm level.• Alarm in working order (yes or no): Date of last pumping. Comments (condition of alarm and float switches, etc.): MSTRMUTION BOX: Of present must be ope ned)(locate on site plan) Depth of liquid level above outlet invert: C> 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.): 2s xsx �CiP(�r�ll��gp C o P� C fir i�Cp i�N)� N F( h» r�✓i ►lf Ql�i1 Ca ff C7 C_I L S. et^� a �. r :'✓' .� PUMP CHAMBER (locate on site plan) . Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appuct nm= etc.). Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address: ;g t a q Owner: Date of Inspection; q Dy SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number. _ leaching chambers, number: leading galleries, number: ✓reading trenches, number, length: /f �� fz�,cictCe�S leading fields, number, dimensions: overflow cesspool, number: innovativetaltemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _EtK ff F=-1 &D i--csc11�S AA' � 4 .t/l� �c� t C'�i�GE c5 I— �0NP(n�G—, OSA ��e t �{L i?nt.. 064 Ue%r-s T7%�. . CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth —top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction - Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: &d—(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.): Page 10 of 11 OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �;Z t P-) a pe cue JJ Fn -f "4 Owner:__ Date of Inspection: SIETt;M OF SEWAGE DISPOSAL SYSTEM Provide. a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 fed. Locate where public water supply enters the building. Uj Page 11 of 11 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a I 9ci i u 2vi pt rte ,s j Owner: b9►4 P wy� Date of Inspection: SM EXAM Slope 2 Surface water Check cellar Vi0 Shallow wells �c Estimated depth to ground water 1-/ feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on recd - If checked, date of design plan reviewed: 4_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain - You mast describe how you established the high ground water elevation: Sys'. r .� 3 �.c I � � ✓l comet i ✓�eu eF ��y� N � d W Zf.. E D a U. c z tA o a� a I -U >- z 0 70 Hd.ON �Q QO t\ w > W a > _ O `o OLL a Q n d c O CL. r Q p Q N o c ... . 6. Q Z IA L Z N O w v O m W F•- Q G. Z m 0 ,. O 0 .0 O cO z c 3 y W A O m c O tZ r•- � ovlot »�• c 3 - +° _ tai { ro O v O •N O ° \ ...° �� =• a> rte. Cd W Mot rr♦ 0.++ � d BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext. 32 October 16, 1992 Mr. Scott Giles 50 Deer Meadow Road North Andover, MA 01845 RE: 5 Turnpike Street Dear Scott: This is to notify you that your septic plans for Lot #4 Turnpike, North Andover have been rejected for the following reasons: 1. No profile; also elevation of bottom of bed. (N.A.6.02b2 and 6.02r) 2. No locus plan. (N.A. 6.02b5) 3. Elevations of soil and perc tests missing. (N.A. 6.02j) 4. No wetlands disclaimer. (N.A. 6.02o) 5. Elevation of driveway missing. (N.A. 6.02p) 6. Downhill slope, y/x, to be shown. (N.A. 6.02u) 7. Location and elevation of foundation drain required. (N.A. 6.02v) 8. No seasonal highwater table elevation referenced to benchmark. (N.A. 6.04b) 9. Distance from dwelling to leach area not stated. (N.A.6.03b) 10. Need note stating that excavation of topsoil and subsoil shall extend at least 6 inches into the natural pervious material. (N.A. 2.18) If you have any questions concerning this letter or the North Andover regulations, please do not hesitate to call me at the Board of Health Office on Monday, Wednesday, or Friday. Sincerely, fd- VL; Sandra Starr Health Agent PLAN REVIEW CHECKLIST ADDRESS /aA/yL,�.�� ENGINEERS GENERAL 3 COPIES_ STAMP C� if LOCUS NORTH ARROW SCALE C— c/ CONTOURS PROFILE/ SECTION "' BENCHMARK SOIL & PERC INFO ELEVATIONS�',� WETS. DISCLAIMER �� WELLS & WETLANDS WATERSHED? DRIVEWAY_,4,_(Elev WATER LINE FDN DRAIN✓ SCH40 (/ TESTS CURRENT? SEPTIC TANK MIN 1500G. ✓ .17 INVERT DROP GARB. GRINDER 7(+200% EDF) 25' TO CELLAR MANHOLE TO GRADE ELEVJ;� GW D -BOX ago SIZE # LINES FIRST 2' LEVEL STATEMENT INLET OUTLETL6 2 = - / Z (2 11 OR .17 FT) TEE REQ' D? LEACHING RESERVE AREA 4' FROM PRIMARY? (%J 100' TO WETLANDS L,,-"2% SLOPE 100' TO WELLS 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW' 325' TO SURFACE H2O SUPP c.l" 4' PERM. SOIL BELOW FACILITY �- MIN 12" COVER FILL? �25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd 6,,- SLOPE (min .005 or 6"/1001) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN TRENCHES? t/ IN FILL?JL,,`_ MUST BE 10' MIN. L' 4" PEA STONE? DK BOT VD X LDNG + SIDE ['160 X LDNG 104 = TOT , (L x W x #) (G/ft2) (DxLx2x#) Health' ;...indover,Mass APPROVED DATE Provided! Title V Reg 2.5 �Ej • SUBSURFACE DISPOSAL DESICK CHECK LIST LOT%1 ) DISAPPROVED DATE -_,Z- 1- 5 Reasons: 1, 1',E�EI?�� �c�, i� tJ►1 ��'�i' cOclO AUT i -'ii( ClASE Zp 4,-5 5 TW &• IUD') FROA 51 it i o tN Loz 3 Is srD� ,tib The submitted plan must show as a minimums a) the lot to be served-area,dimensions lot C abutteve 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 dimensions of system -including veserve area f) existing and proposed contours ;g). location any wet areas idthin 1001 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 1001 of sewage disposal system or disclaimer -Planning Board files J) known sources of water supply within 2(iI of sewage disposal system or disclaimer k) location of any proposed well to serve )ot-100I from leaching facility 1) location of water lines on property -101 from leaching facility m) location of benchmark n) driveways 1 N T��S o) garbage disposals p no PVC to be used in construction q) profile of system -elevations. of base an: plumb, pipe, septic tank, distribution box inlets and outlets, die-.:•tbution field piping and Other elevations r) maximum ground water elevation in area sewage disposal system s) plan mast 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. (b) cleanout (c) ;101 from cellar wall or inground swimadng pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) pe greater UM 0.08 Reg 10.E b} sump 9.6 b) stand-by power b fj c6 Design Check List a Page 2 FAIL OK x LeachingPits _ Leaching pits are preferred where the installation is possible Reg 1.1.2 a) calculations of leaching area-rd nimum 500 eq ft 11.4 b) spacing 11:10 c) le) surface drainage 2% ?.1.11 d) cover material 2I x2' x4" splash pad f) tee at elbow g) no bends in pipe from d-box to pipe Leaching Fields Reg 15.1 a no greater t'=an 20 minutes/inch barea-minimin 900 s4 ft 15.4 c construction of field gW�)r `/A'I�1/yt,_� 15.8 d) surface drainage 2 % 3.7 e) 201 from cellar wall or inground swiradnt , pool Leaching Tcenches Reg 14.1 a) c onst%aching area-min 5W sq Pt 14.3 b) spacing-4 ft min 6 ft with reserve between 14.4 c) dimensions 14.6 d) construction 1.4.7 e) stone 14.10 f) surface drainage 2% Downhill 8122e a) slope y x = be shown) b) y/x X 150 - (to be shown) EMS Reg 9.1 a} approval 9.6 b) stand-by power - �URA/Pi KZ_ AS -BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations House / 1-1 /,A 7 Tank IN J g D, 77 Tank OUT /a O, C_�-,;Z- D-box IN D -box OUT Trench Inverts Line 1 /oq o l b - Line 2 11q, 6 - Line 3 11P.0 - Line 4 //7, d - As -Built Elevation i�L1•l,� 1,526), 7,9 S�1, i o.37 --119,74- 118,96 -119,74- Bottom of Exc.% Stone OK? " XD -box checked? Pipes cemented? a 011 c p �j Z Q L •♦s O 3 0OjER = r c 0 ro Z � ✓ w O Z a L Q U 0 � a c p � � Q L c O 3 Q = r ro Z � ✓ w O Z � � � U c a 3 ro Z a L Q U 0 � a O Q bC0 � p a� c = 0 U 0 O �• 3 .a o N r.+ C ro ro t .0 N L N Q 0 �7 N E ro L acu V Town of North Andover, Massachusetts Form No. 1 NORTH d BOARD OF HEALTH 19 A 4 ° ° Ew°• APPLICATION FOR SITE TESTING/INSPECTION A�R-Aq TED PP0.�GJ . 9SSACHUS�� .. !� Applicant I V�.A ' NAME Site Location_ T4 I -11P Engineer c � NAME Test/Inspection Date and Time_ Fee f 1 4;-� 3 CHAIRMAN, BOARD OF HEALTH y/ Test No. "DUS S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. kq, X�'114­1 �zI� X,.`i:`5. Ai '80N" kV -z .... . ... . 1 ��. iii' I Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT WELL LOCAT ON GEOGRAPHIC DESCRIPTION Address���O N (9 E a of (teed (circle) City/Town''/CSl'' '+E�• �fl( Alx7i-MYJls� - Well owner SMG 150441-1041V C 0 (road) Address �/SU)A.5/ij/✓ /off/ UMN S E 0 of ^�y '�y,� j1 (mi, in tenths) -Q (circle) �,} (! rY//' intersect. w,1_91W olez' s `6 Board of Health permit obtained: yes no ❑ (road) WELL USE WELL DATA Domestic I] Public [] Industrial ❑ Total well dept I ft. Monitoring ❑ Other Depth to bedrock 4r S ft. Water -bearing rock/unconsolidated material: Method drilled Y Description Date drilled r2^ , Water -bearing zon,,e��sa,:���', CASING t) From To 32s' TypeE� L 21 From To Length F0 ft. Dia(.I.D.) in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout.❑ Other106MOC- Slog length from_ to STATIC WATER LEVEL (all wells) Static water level below land surface J0 ft. Date WELL TEST (production wells) Drawdown Oft• after pumping hr. min. at gpm How.measured k�C[ �' Recovery 'lip ft. after__'�!_hr. min. LOG of FORMATIONS COMMENTS 8 Materials Feorn - To , Fi.CC o /6' rUrgcaJso�/ �; Dnlle�3:. M£ C{1/GLS, Firm r X/7 se CC. fry Address` City/TownC Super sing Iler R g # n-----" {"" i tvrewl'aupePvrrsshig'-registered well driller Please Prim firmlY- BOJ RD' -O -F.` ;HEALTH' .COPY NUMBER FEE 3�o THE COMMONWEALTH OF MASSACHUSETTS $25.00 TaWM....--- of.......... NCLRTx_•ANDauFR--------------- ------------- This is to Certify that .................Wilmington Pump ....................................................... NAME 639 Woburn Street, Wilmington,_ MA 01887 ........................ IS HEREBY GRANTED A LICENSE For .......... 1,ot... #5..-T.UrIIP2i.-lie---Strgeat------------------- •-----•---------------•-•-••------------•-----------•----•---•--•••-•-• ••----•-•••-••----•...--------•---------••--•-------••---•----•-----•-••-----••-•--••--••-------•--- ----•-••----------------•--•-••••••••---•....------••-•-•••-•--•-••-••-••----•-••---•---.....--------------...-----•----•----••--••---•---....-•----•-•----•--•••----••---- ---•----•--•---•-----••----•--•---••••--••-------••-•--•-•--•-------•••------••---•---...----••...-•-------•...--•---••................................................... This license is granted in conformity with the Statutes and ordinances relating thereto, and expires ------- December31, 1993 Unless sooner suspended.. _ evoked. t. December. 4' 19 -9.. • --------- ------.............. FORM ass HOBBS & WARREN. INC. P BOARD OF HEALTH Town of North Andover,Mass. Permit # Date %.-> 19' APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well ). Application is made to install ( ) a pump system'. Location: Address SA uEm "7-ued ,rte ll�" V ����' 1 Lo t #f _ Owner A d d r e s s 4f,(,1 Ni>y/�/i�UE/��T el. Well Contractor( Addresses Te1.,�SSh Pump Contractor Address Tel.. WELL CONTRACTOR .(To be completed at time of purnp test) Type of Well i>C� Well used for -Diameter of Well �`� Size of. Casing" Depth of Bed Rock wS Depth casing into Bed Rock 45-- o la'«IG Was Seal Tested? Yes (19) No (—) Date. of Testing Depth --o- Well --' Well Ended in W.ha.t. Material Depth to Water_ 15,0 f Delivers S Gals.Per Min. for 4 hours Drawdown feet after pumping—_hours-at ^_ CPM Date of• Completion 1�:� %�,7w a-,, r Signature Well Contractor :�:t:tiX�:t:;:;:'c::� •'•:::'::;:;. _..a........�,.:: .......,.::•�::••�•:::: •:•;.....,.. c .-:':�:;::;c::•�•�:::::::. :cam* PUMP INSTALLER (To be'' filled in- before installation) S•i ze & Name Pump _ _ _ _—� _ Pump Type Used Water Pump Delivers GPM Size of Tank Pipe Material Used in Well: Cast Iron (—) 0:11vani.zed (_) Plastic (_3 Well Pit (_) or Pitless Adaptdr (_) Was sleeve used to protect pipe? Yes.(_) NO(_) Type or Name Well Seal Date �4�4i1r14��r�r�4i�rt4►'ri4��r�rC��r��r�M�a�C�r�'t�M�k�1ri't�4�Ytilr4e�4�'eti4�1r�4�Y:4�4�r:'t�r�rr�e:rtietit,:;::"::,:,r::ir,.;:ta,::::r:: �:::r, i , , , Date Water analysis rep6r--t 'submitted to Board of Hical,th Date release given to owner of record & Bldg.. Insp Health Inspector 62(/XCIZ�161Z &6 kww- :kvrdteadeff Xaiforatatp, Atc. 66 LITTLETON ROAD WESTFORD, MA 01886 Report Numbers C-wpa-7528 Clients Wilmington Pump Supply Inco P.O. Box 517 Filmington, MA 01887 Sample Taken ay! WP8 Staff (508) 692.8395 FAX (508) 6920023 1.800.649 -TEST Report Dates Dec. 11, 1992 Sample Taken Ats Chester sul.livan Turnpike at. N. Andover,Maes. ons December 10, 1992 CHRTIFICATE OF ANALYsis TEST PARAMETERS EPA Max RESULTS VNITO Total coliform (P) 0 0 Per 100ml calcium No Limit 65.9 mg/L Capper (s) 1.3 <0.01 mg/L iron (s) 0.3 4=0-:_Q-8, mg/L Magnesium No Limit 10.2 mg/L Manganese (s) 0.05 <0.01 mg/L sodium 20 18.8 mg/L Potassium (S) No Limit 7.5 mg/L Alkalinity (s) No Limit 162 mg/L Ammonia No Limit <0.01 mg/L Chloride (0) 250 26.7 Mg/L chlorine (total) 0.7 X0.02 mg/L Color (B) 15 10 CPU Conductivity No Limit 445 umhos/cm Hardness No Limit 207 mg/L Nitratee(as N)(P) 10 0.09 mg/L Nitrites(as N) 1 +40.01 mg/L pH (0) 6.5-8.5 7.3 ou Odor (8) 3 .60 ,� TON Gulphat®s (B) 250 15.6 mg/t, Turbidity 5 3.3 NTU Gediment pod/nag poo NT -Not Tented, #-Value Exceeds EPA STD, TNTC -Too Numerous to count *=Background Bacteria Noted, "-EPA Advieory Limit FvExaeede EPA Advisory Limit (P) -Primary EPA standard, (S) -secondary EPA standard (may affect aesthetics of drinking water i.e. taste, color, etc.) Thie water sample, as teited, is considered SAFE to drink according to EPA guidelines. However, one or more of the parameters exceeds EPA secondary standards as indicated by the (f) sign. Massachusetts state Certified Michael P. Carlson, for.. Testing Laboratory I#MA048 Thorsteneen Laboratory Inc. WELL DATABASE ADDRESS: AGE OF�'N =�� ilii 7 T t 2i,� LL D R-1L1.�.... y -y"- r Yz 4ti i 'WELL LOCAT 0of: --Vf'LLL.PL� b T-73,' jE: l'�2 (� �j�. DEF7HGF WHT -=E:OF WELL: DRILLED' b. DUC L -OW - -- _ �A��v�s�sDA - �LGgtir�c�ALti� a ELC�LE�ON _N O "T CQN"L`�A-N-L"S: .Y r�i —ti -L DATAB?_SE ADDRESS: l c- %` �tiv ✓�� S AGE OF W=r. 'v E L.L. DRD:I. WEL L PERM T- WE.L.L L OCA70 WELL PFR2�fl i -DATE:'`: DEPTH OF WEL1:k TYPE OF WElL: a . D=LFD b. DUCT c. LFK:, 07wN TYPE OF WATE R.3EAR DNG ROCK: WATER ANA YS?S DATE: HIGH _NLA NGAv-ESE: Y N =- -- i"RON: Y N OTN�=R CONTAIN A -NTS: Y N GlVzry r-1 IK rA rA R v x 0 L2 A Qr Mui .s—o o a� c 21-. Cd C) 04 o Z m Lo Ea g� CL L � W o c. N Om V y0r ts cm >. X. ®R m :m o - y: � 3.. 44 cccom d% m Cc O .� m � = C N O C O co, m O O ft: act m N m � cm moa r: a, CD •o m � m v v� o 0 > Z Joaocm Qm cc) •o = m a) � c N ~ •O•. h m •O+ ~ m COD • AS N O.Z O C Z ac •E CD •N o � m om a g VD o. m _ A .0 ` H 7 O H _ $ aim I c O CD i 0 o � z Q O y D = CD o, CO2 o c �E m m C13 0 CD � O.a O i co C CD O L m O a- cmQ CO) C _v R I 'p .Q O CD Z CD C2 CL V CO) Cl) O W Q LL LL U 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** ,5-06 APPLICANT: �. S �r f I�i UG h _,L /��' Phone C T LOCATION: Assessor's Map Number Parcel 2 e l0 C O/,p` � Subdivision 140 Lots) W' Street+ /G(x,,-y St. Number :21e ************************Of:Eicial Use Only************************ cR�ECCOM EENDAATIIOON�S OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments r�'�' -K5GhJ- Town Planner Comments Health Agent Comments Public Works - sewer/water connections Date Approved If Date Rejected _. Date Approved Date Rejected - driveway]permit � A / -/f, LAWI_Iory (moi rs'/CC Fire Department Received by Building Inspector Date I CERT/F/ED FOUNDATION PLAN S LOCATED /N Na:`,PwoR Ma,. SCALE / �' DATE tR q3 Scott L. Gi/es RL.5 V) 50 Deer Meadow Rood North Andover, Moss. .. 0 L OT 5 u - .. u o 4 r\\1 M EK�ST�ntCz T p, ic1, 0 to 1 T s - I ` ►50.00 TURNPIKE 5TUfT / CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BU/L DING /NSPEC TOR ONLY ��E' f SHOWN COMPLY AND SUCH USE /S FOR THE WITH THE ZONING DETERM/NATION OF ZONING BY LAWS OF CONFORMITY OR NON-CONFORMITY �NEtZ,Mp,. WHEN CONSTRUCTED: t Lam WHEN BUIL T. Y Z���: 7 hzt �J 1 I I, h hV W t„ _1 1 I li 1 r � h 1 v° a v� , z � r 1 I I, :v 1 I 1 r � 1 7F6, ¢ , 2 � S CERT/F/ED FOUNDA TION PLAIV LOCATED /N Na •oR MA - SCALE /= DATE- Scott L. Gi/es R.L.S. 50 Doer Meadow Rood North Andover, Moss. I 0 U 0 r .0 oT 4, 9 g Z He�aY c��Tt�y -GNAT s K) NAVE t►.ISP6cTED I'VE. CoN- Wn.k_-TW4 OF Tt tts DtSR:5�1__ SyS--e-m A"p THAT 7,L{6 cx:*A- ST�tJ�T1o4.� ANy F:( 4At_ GRAat►aCz "Ns 5SE'k t m P zc- otZbANcE k/ rn{ T"c- r�eS- - t6iNCVS IQTG:' 1T AND 1WAT Me- MATeQ:IAL-S USED e.0WlW RM 'Co. TµE PLAP4 SP�21F1EATIDt tS AND 3�0 G.M. 15�� L OT 5 V, s . - E, �' X50.00 TuR,mPtylE 5TR,f_fT aS-BUILT E:LEU.= INV. OVT IM TAMIL = RIAS' . " 0L r TA lK = MP.1S' " ocrr BoA =4-_iW.37' " Fµt7 MPE t= 113.74 " Z u8,3o 4 g7.25 Mn / CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE SU/L DING /NSPEC TOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE goy WITH THE ZONING DETERMINATION OFZONING Q1 BYLAWS OF CONFORMITY OR NON—CONFORMITY ►alp, %NU�/EtZ,MA,. WHEN CONSTRUCTED. 'sy'-'S'ERE, WHEN BUIL T. r. M �+ a Oo 1� t► !.� �ykgi 1•r#jF XJ I JN �ykgi 1•r#jF XJ