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HomeMy WebLinkAboutMiscellaneous - 223 FOREST STREET 4/30/2018 (2) 223 FOREST STREET r 210/106.A-0077-0000.0 u 05N; ti t 1 7✓v } Lot & Street OkE 5T fiP. F-6% Map/Parcel e4679 CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: 71MApproved by: Designer" -B&-W 05600-b J /2 - Plan Date: Conditions: Water Supply:- Well upply:Well Permit: _..Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria H Date Approved Plumbing-Sign-Off: -Wiring Sign-Off: Comments: Form"U" Approval: Approval to-Issue: YES NO JJ Date Issued By: - I Conditions: Final Approval: ..All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO i Other YES NO Any Variance Needed? OYES NOr— FINAL BOA OF PEALTH APPROVAL: DATE: APPRO BY/ SEPTIC SYSTEM INSTALLATION Is the installer licensed? YES NO Type of Construction: NEWPA ------------- New Construction: - .Certified Plot Plan Review YES NO --Floor Plan Review YES NO _ Conditions of Approval from Form U YES NO _Issuance of DWC permit: - NO _DWC Permit Paid YES NO DWC_Permit#- Installer: le 44 _BegirLInspection:_ . -- S NO ,Excavation Inspection: Needed: Passed: V2 < By. - -_Construction Inspection: Needed: As_BuiltPlan Satisfactory: YES: - Approval of Backfill: Date: IZ,Vj,-2By: ---Final Grading Approval: Date: z} By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: /C, 4 Commonwealth of Massachusetts City/Town of No Andover 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. i A. Facility Information Important:When filling out forms 1. System Location: on the only computer, ��r�S S4 use only the tab oC�� JC � key to move your Address cursor-donot t,\, -1� D1 -Ovo use the return ) t -- key. City/Town State Zip Code 2. System Owner: Obra- Name tum Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed coo�dition of component pumped: 6. System Pum d By: Name Vehicle License Number Stewarts Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: $so- ill st bradford ma Sign a of auler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 NEW ENGLAND ENGINEERING SERVICES INC June 10, 1999 I Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 223 Forest Street septic system design Dear Sandra: Enclosed are the following documents regarding the application for approval of the septic system repair for the above referenced property. 1. 5 copies of design plans. 2. Soil evaluator sheets 3. Check to cover the fee. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., EIT President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)688-1768-(888)359-7645-FAX(978)685-1099 May-27-99 12 : 45P North Andover Com. Dev . 508 688 9542 P . 01 SEPTIC PLAN SUBMITTAL FORM LOCATION: ZF. b,��s� NEW PLANS: Yl S $125.00/P1an__--41/ - i i REVISED PLANS: YES S 60.00/Plan SITE EVALUATION FORMS INCLUDED: CE) NO DATE:_ --- DESIGN ENGINEER: r DATE TO CONSLtL.TANT: G 5 azrk *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary, I A�DDVEFt/ TOwN of Of EAt-��p a Jun-17-99 10: 10A Paul D. Turbide, PE/PLS 508-465-0313 P.04 I June 17, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St, North Andover, MA 01845 RE: Title V review for 223 Forest Street i Dear Sandra, I find that the design plans adequately address Title V and local regulations. Various local upgrade approvals and local variance requests are noted. In my professional opinion the requests seem reasonable for the conditions of the lot. (One comment is that this is an existing 3 bedroom dwelling,but the design calculations as to size of leaching bed are based on a 4 bedroom dwelling. The review of this design was treated as an upgrade of a failed system for a 3 bedroom house. if an additional bedroom is added in the future(to make a total of 4 bedrooms)the system will have to be brought to"new construction" standards. (One area where it does not meet new construction standards is that there is no reserve.)) If you have any questions or comments please feel free to contact me. Sincerely Carlton A. Brown,PE/PLS Forest223.doc Ai�) PORT ENGINEERING, Civil Engineers Land Surveyors One.Harris Street Rewburyport,MA 0}954) (978)465-8594 Town of North Andover f NORTH OFFICE OF ��0 41 COMMUNITY DEVELOPMENT AND SERVICES A 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT SSACHUS� Director (978)688-9531 Fax(978)688-9542 July 20, 1999 Ben Osgood, Jr. New England Engineering 33 Walker Road, Suite 23 No. Andover, MA 01845 Re: 223 Forest Street Dear Ben: This is to inform you that the proposed septic repair system plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, —",',-j"Zi Sandra Starr,R.S. Health Administrator SS/smc cc: Guggenberger File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NEW ENGLAND ENGINEERING SERVICES INC August 8, 2000 I Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 223 Forest Street,North Andover, Septic system design Dear Sandra: Enclosed are three copies of the as built plan and the certification for 233 Forest Street. The certification form needs the permit number and date added and it needs to be signed by Mike Reilly. If you have any questions please do not hesitate to contact this office. Sincerely, Benj7m C. Osgoo , r., EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 i INSPECTION CHECKLIST FOR SEPTIC SYSTEMS k Yes NO ;ti,,bsr /5 A. Bottom of Bed Ji 1. Excavation to proper depth 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Comments: B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed !) 3. Wall minimum 10'to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90°change 10. 10'minimum offset to water line Comments: i D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20"manholes 7. Inlet tee minimum 12"under invert b� 8. Outlet tee minimum 14"under invert 9. Outlet line cemented 10. Air space 3"above tees 11. 2"-3"drop from inlet to outlet 12. Pipe set 13. Compact base with 6"of V crushed stone under tank 14. Tank is watertight Comments: L Yes NO E. Pump Chamber 1. If separate from tank,c act base with 6"of/<"stone underneath 2. Minimum 2"pipe to d-box vity system 3. 20"access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box I. D-box level 2. Minimum 0.IT'(2")drop from inlet to outlet 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box ✓ 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double-washed-'/I'-- 1 '/z" _ -pea stone / Bucket test done? v j/ ���✓-c.� 2. Minimum 2".of pea stone above distribution lines ✓ ��/l 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not,then swale. Comments: H. Leach Trenches S�L� 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan-Minimum 2%maximum-4'. 4. Vent present if<50 feet or specified 5. Distance between trenches minimum 4'and maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6"per 100' 8. Depth of trenches below outlet invert minimum of 6". Yes NO 9. Pipes set on stable base. Comments: 1. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipe 6'maximum . 4. Pipes connected at end 5. Separation between adjacent fields 10'minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: i I Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond Town of North Andover, Massachusetts Form No.2 NpRTM BOARD OF HEALTH 9 /Q 3? *!,f. - .• oL � O r e DESIGN APPROVAL FOR ,.... .. i �SSACMUSE4 SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM r t Applicant Test No. r Site Location A192 Reference Plans and Specs. DESIGN DATE i INEER � Permission is granted for an individual soil absorption sewage disposal system to be installed t. in accordance with regulations of Board of Health. �• CHAIRMAN,BOARD OF HEALTH k �• //ln� i' Fee � , Site System Permit No. l/ r i• :q.f ',....• ,,. 'XJ ';.,:- t T. ..:.. f.f :; ,.,}s ,>. .<Ps:r,..¢'.t+4'f.Fn }55 „r' 4r, i.'�s .g.4 rtt3•+ r'. rJ; d r : 'td _ .it:•: x: �.� ,; Jr$:3•Y;c s } ,t t,,,,},.A. fF s• {a_ 1•r•S rs: :},. :±- f' i i +.tt. 3 i'°aa r x ;�d- - ',P„t, .(. d , �. 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S 7• tt: 0 46 c. €t.•, !'::, r .; e:'iit t, f.. . .�:1, yFP^, #i.x it..:t •i ;P:•.•i:;•.t,. #�f 6:;' r a-t, •fa,a. -t I. .:Edd,y a Ica.,. h r'r..f`+,.Syi 1. s- ...u1. 3{.r f,. i'_. { i- Y d:: r : 't' i t •'I. f, r ' _7 ,t. .. it. :2 3. } y'.,.2 a:h. - -r t�% .I.i l 3r•:k's fS° ;t. }P��` f i '1-i ➢ t- r •r ,.4 s, a r. a : ,� -,a. •+f "'kf - t,}! t {' R t':�, .. tr'[ h .ar. i­,' - - - ,i r. .7,i.1:'}• 4, g� ..y �:r)': ,r`15 r•i •#ir: .:i�. t f I - tY: ,.a(F t - }}: i �P-:• _�" rta, .�s rld ,.k<.•l,r. I a t. t 1 -t 1 - •'{i �x'7 . Jai � r t; r dfi'a�d}ai:t;z:atriiaa - t I f r it _ i d Town of North Andover, Massachusetts Form No.3 s f pORTH BOARD OF HEALTHA. ast; t r p 19. 9 . z - ,SSACHUSEt� DISPOSAL WORKS CONSTRUCTION PERMIT - - - Applicant P qL NAME i ;R ADDRES � TELEPHONE � r3r Site Location , Permission is hereby granted 'to'Construct ( ) or Repair ( an Individual Soil Absorption sy } f e t Sewage Disposal System as shown on the Design Approval S.S. No. `e 171 t , t. I CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. i + tj 7777 it d t r i ktttk } 7t 7 SAF{ y 5,a r jd • -i. .' ,,-,: s..csa ,r[,S':=� :.:,.5 r :..�.r7� ! i;. F: �,k x,. ir, > 3 ., t d...r, .�., dT. ., f ik y,. l - a t'7 sr+b'4."4':. S '1 �- r rtzs: _{ ir. .L::•.L [,. ,;a1.,. •a .., .-t: :-t .x •.<!ti .... , -._ ,. r•'i r..� ,h:},,. ,.•:hzz.,`7, 11_., :.I,.V:u d 1�[;x �. �tp,� f� tr .�...<'FN P r - :,,. .. - f � .4 # s. t't t t! r$} fd .A t Y,! - r i `y .f r:`{{ tlt f r } C. {(j ir• L { f t .,ri.� Lta•t._,' '::�� r..'. _� - � � c... Ft �- k r ,4 rct�r.,•:R�cwy',-[ F. s y_ xr rf« 5.; x - ..t i crrr`r { r tdr . e. - P.. r•.f ItS. E G s ttl.t.r - d, -3f ,_r,,#.� y ..: i ..:r.:,) i 1•.'� -f.>,' t1 i i ii. �FF::'P}v?.rip."�•° ,_: J { .k tc�.. #. - ri•tTr r �',. Pi t _ t ;'S +S' Yta .rt.t t - : _l �.).rt!=y t ,it (t•,N ai 'i z. �.P a f,11 t;r ': { ar t.Vii. 3 - .,5. r 1i kf- 5•,, Tdd„ ait.,.i. t xd.� � t t�. r ��, e5+�'k'�'.{'�- t: 9eP � aYl• - '� f�� �} / y� - ,•#�, t ,-:4, ,} (� �t '`,-f; t •f st ri}zv='4'?>"E t td. e �. � r Y a:�s}r,rsa t i .e 1. t ria 2 ,r,y a.rti kt f t ,t .}, I'2 .,t s.l3t .rlt,r t uti-tl t.t (', �h f ?x yfat .: a :"t {,1.} ,a k 4!'f ey.! ,q,t '1 5,.„ f ;e 1;, tt{t,t{i.`F. a r.�y.y... k? ,sem ,tr .rt�x rt !:�', r C � d73 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: i_C(_q CURRENT INSTALLER'S LICENSErc LOCATION: LICENSED INSTALLER: P-, P. R \y : z ,n C , SIGNATURE: TELEPHONE," C] CHECK ONE: J _5­7 ZID REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 575.00 Fee Attached? Yes t/� No Foundation As-Built? Yes No Floor Plans? Yes No Approval - Date: y 4...+ '*tv` •x :-+.i _-.1` :`:t.'}. :..ice_::a�•N?t% :12: ;I':sz_i.•.$�' .`. F I I TOW N* OFN ORTH ANDOVF,R srNVAcYr DISPOSAI: )-STE1I I-STALLA-riON CERTIFICATION The underslimed herel-W certify that the Scwa2e Disposal Systems i. ! cor.suuctcd- (Y) re^aired: V located at 2 2 3 4z' � _- was installed in conformance with"the North A-n% over Board of Health acproved plan, System Desi1m Pet:r't = , dated :vita an ancroved design [low of !ons per day The materais used were in conformarc: :vit't those specified oh the approved- plan; the syste*n was instilled in accord*are,- ,�th'the previsions of 3110 CNfR 15.000, Title 5 and local regalatiors, and the final aradic agrees substantially with the approved plan. Ail work is accurateiv represented car the As-built wl� ch has been submitted to the Board c-'Health. Bed inspection date: o Co 6 Ent?ineer R:pras.z :zti�e Final inspecuon car: _� o 00 _ L (, (iAI _ E-ngir.eer Rzpresen[at:-.e Installer: Date: ✓ Cesisln Ens_ineer: Date: a RICHARD c4C TANGARD i t` - - a AN LN COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION ,r V'v ZE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: 3 E&fa -t e -- Date of Inspection: RECEIVE Name of Inspector: (, lease print) \- om ti OCT 0 Company Name: 2��4 Mailing Address: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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: 7X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector'Signature: Date: 7 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. 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. r Title 5 Inspection Form 6/15/2000 page 1 ,Page 2 of 1 I d : >1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: e Date of Inspec ani: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A: Syspm 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. 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: 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: 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: Page 3 of i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: AJC, 01VD4 vnK Owner: 6 h Y Date of Inspect . V urther 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 ing 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: R Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if 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 systerri 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 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: 3 . '*Page 4 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Forts Cl cj O A1,Q )Ve 1 Owner: Date of I spe ' n: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _-"A ackup 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 G,'Eiquid depth in cesspool is less than 6"below invert or available volume is less than Y2 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. f _ ✓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 compomads 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. E. Large Systems: To be considered a large�S stem the system must serve a facility with a design flow of 10,000 d to 15,000 g y Y ty g gP gPd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. 4 • `Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: � � /•'/�1"P_S/ ��- Ala, 0NC»yP2� Owner: Date of InspecAo : Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No L-"' Pumping information was provided by the owner,occupant, or Board of Health ere any of the system components pumped out in the previous two'weeks? fHas the system received normal flows in the previous two week period? L----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) c/" 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: Yom/ no 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) [3 10 CMR 15.302(3)(b)] 5 Pjige 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Iff4eciti6di FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: , Does residence have a garbage grinder(yes or no):du Is laundry on a separate sewage system(yes or no): d p[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): /-f r f/ +°v- /p v Sump pump(yes or no): /`t 0 Last date of occupancy: a0 e UY11 e- , COMMERCIALANDUSTRIAL Type of establishment: /4 Design flow(based on 310 CMR 15.203):_ gpd Basis of design flow(seats/persons/sqft,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: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: f `/✓ Was system pumped as part of the inspection(yes or no): 5 If yes, volume pumped/SQO gallons--How was quantify pumped determined? 7/2 urlL ,life r-rle- Reason for pumping: f' + rte % r'v 2 4,. TYPE,OF SYSTEM ( peptic 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): Approxi ate age of all components,date installed(if known)and source of information: `7—V P'4 Were sewage odors detected when arriving at the site(yes or no):A(o 6 ` ,,Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: (-?1 . Date of Ihdpectto{n: U ! BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 440 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): . SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of slupge to bottom of outlet tee or baffle: -33 Scu, thickness: 2i'' t - Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: / q How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): / L✓%G F S ?`/SAN/cl Tn f u ► GREASE TRAP:_(locate on 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.): 7 • Page 8 of 11 E OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A,23 Owner: Date of Inspect o$: �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.): L10(if DISTRIBUTION BOX: present must be opened)(locate on site plan) Depth of liquid level above outlet invert:4110 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.): UX (� 6U1 el"'L /-I n / 779 ,-/ — /--E L. (r� trV`1 D >�,►' .c/u '/�� 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 appurtenances,etc.): 8 PAge 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S/ ' Owner•66 e Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):X-6(locate on site plan,excavation not required) If SAS not located explain why: . a , Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: _Teaching trenches,number, length: Z leaching fields,number,dimensions: /-/G/ii 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.): x:-'14/e-[i 2 F CESSPOOLS:--!(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on stte plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address:,-ZZ-3 e; S A) HAIe x— Owner: ')A e Date of Inspedi n: 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 wherepublic water supply enters the building. O oA o We l 10 ' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART C SYSTEM INFORMATION(continued) Property Address: / Owner• A, o Date of Inspec ion: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check).all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: r 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: � 19GLl is ki MA Gni 11 i 1 � r NEW ENGLAND ENGINEERING SERVICES INC March 8, 2000 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 233 Forest Street.,North Andover Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system failed our inspection. If there are any questions please call me at my office, 686-1768. Sincerely v B C. Osgoo /, E.I.T. President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 .� I 6 MMONWEALTH OF MASSACHUSETTS � EXECUTIVE'OFFICE OF ENVIRONMENTAL AFFAIRS , 4 DEPARTMENT OF ENVIRONMENTAL PROTECTION :>:; ^- ONE WINTER STREET,BOSTON MA 02108 (617)2924500 ' TOUDY.CO ARGEO PAUL CELLUCCI DAVID>B•BTRUFiB :: Governor Commiscoier;i` SUBSURFACE SEWAGE DISPOSAL SYSTEM{NSPECTiON FORM - :;__.•: , PART A _ CERTIFICATION ff Property Address: Z Z3 f fc:,! St Name of Owner v i; b f —�- ^1- PW C--,^Wr[C Address of Owner: 9.Z 3 3�i2 RzL's 51� �- i Date of Ins Name of Inspectors(Please WBenjamin C. Osgood,Jr. am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310-CMR 15.0001 Company Name: New England -Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover, MA Tetepbone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that 1 have personally Inspected the sewage disposal system at this address and that the information.reported below Is true,accurate and complete as of the'time of inspection. The Inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspectors Signature: Date: Da The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)wkhin thirty(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 Department cKhvironmental Protection. The original should•be sent tottu system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS THIS j p- )1 q 4. Yl-i is RIs PZ)12 1 L> (:I rJ 4- 'r1�� p w Eta aF Inc fRo pE2iY f'-)&C �,urA/1 WtTNFA5IF-D is revised 9/2/98 Patel of It SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION CORM "lF,tr PART'A CERTIFICATION(continued) �s =; Pioperty address: �,✓3 i`esT s i• N- �qn/� <f± = ti Owner Date of hspection: INSPECTION SUMMARY: Check A, •B, C, A� SYSTEM PASSES: I 1 have not found any information which indicates that any of the failure conditions described In 310 CMR 15:303 exist. Any failure',:`::`,. criteria not ovalklated are indicated below. i COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be'repiaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N.or ND). Describe basis of determination in all instances. If"not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)Years prior to the date of the inspectioh;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken,settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health). brokenpipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ - The system required pumping-inore than-fourtfines n yeardue to broken or obstivcted pipe(s). The aystam wHt pass" inspection if(with approval of the Board of-Health): broken pipes)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;:c PART A CERTIFICATION(continued) Property Xddress: Z 3 3 fz i s rr s r- N_ �AJ 061 C.(L Owner: JAL)lZ1 G 6,6- Date {,Date of irnpecti : C. FURTHER NkLUATION IS REQUIRED BY THE BOARD OF HEALTH: : I Coriditiohs exist which require further evaluation by the Board-of Health in order to determine if the system Is falling to protect the:' .' public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMWES IN ACCORDANCE WfTH 310 CMR 15.303(1)(b)THAT THE SYS IS NOT FUNCTIONING IN A MANNER WHICwmiLLPRQIECT•THE PUBLIC HEALMAND SAFETY ARID THE EA MONMW-- Cesspool or privy is within 50 feet of surface water . Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES-THAT THE SYSTEM(S. FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS Is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic.tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less then 5 ppm. Method used to determine distance (approximation not valid)." 3) OTHER revised 9/2/98 Pa`e3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART A CERTIFICATION(continued) Property Address: ES 1 S% owner: 14 v 2T G v cT cT t% (�L 4 G_et/_ . Date of Inspection: D. SYSTEM FAILS: You must indicate either"Yes"or'No' to each of the following. � LAP 9 1 have determined that one or more of the following failure conditions exist as described In 310 CMR 16.303. The basis for this c7—— determination is identified below. The Bpard of Health should be contacted to determine what will be necessary to correct the failure. Ye No Backup of eewagit Ieto facility-w-ertem component•due rto on overloaded or"ckgged SAS,or,"espool.' Discharge or ponding of effluent to the surface of the ground or 'surface waters due to an overloaded or clogged SAS or cesspool. Y _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. �l Liquid depth in cesspool is less than 6"below invert or available volume is less then 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_.. Any portion of the Soil'Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone 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 60 feet from a private water supply well with no. acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of woo water analysis for -coliform bacteria,volatile organic-compounds,ammonia nitrogen-and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: .. The system serves a facility with a design flow`of 1:0,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: k Yes No the system is within 400 feet of a surface drinking water supply the system•(rwithin200 tootof-*44butwy-t*,&4urteo&44nki".WOWourydy•�• " -- _ the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area iWPA)or a mapped Zone 11 of a pubpc water supply wet) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(21. Please consult the local regional office of the Department for further information. revised 9/2/98 Pate4of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM iNSPECTiON FORM PART B CHECKLISTqA) OiF Property Address: 2-33 �2 cs! e l 667'(,1 N. Owner: Date of Inspection: , x; �Ja1`f� Check If the following have been dorie:You must indicate either"Yes"or"No" as to each of the following: 1 Yes No i Puhtping information was provided by the owner,occupant,or Board of Heath. as+ • _ _ the.@ s emco .kww;baen or✓atlaa:tt�nco.Lvaoks and�We•tyctem haslswc cetaiogweswislAow • �• .None of th y t mpoa.nts pna►p•d+f rates during that-period. Large volumes of water have not been introduced into the system recently or as part of'this AA AA inspection. fV':14 As built plans have been obtained and examined. Note if they are not available with N/A. -The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on the site. 1 _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge.depth of scum. The size and location of the Soil Absorption System orrthe site has been dexermined based on:- Existing information. For example,Pian at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance Is unacceptable) / 115.302(3)(b)) _ The facility owner(and.occupants.lf d'ifferaat lrom.oterner).ucere prnuidad.wiih fafaun■ti^aon 3hA prorr:sntan■^^"f SubSurface Disposal Systems. P Y revised 9/2/98 of 11 SUBSURFACE SEWAGE DISPOSAL; PARTS SYSTEM INSPECTION FORM SYSTEM INFORMATION Property Address: Z3 f? �"b 1Z E-57- %2 7, /V- �/V Owner: Dere of kwpectlon: FLOW CONDITIONS RESIDENTIAL: ' Design flow: g.p.d./bedroorri. Number of bedrooms ddesign)- Number of Bedrooms(actual):_ Total DESIGN flow N}�mber of current residents:_ G'rbage grinder(yes or no):_ Laundry(separate system) (yes or no):_: If yes,separatelnspaction.required Laundry system Inspected (yes or no) Seasonal use(yes or no):_ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no):_ Last date of occupancy: C O M M ER CIA L/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 16.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 6 system:(yes or no)— Water meter readings,if available.- Last vailable:Last date of occupancy: OjHER:(Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection:(yes or no)_ If yes,volume pumped: gallons Reason for pumping: 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date Installe"f known)-and source etdnformstion: -•--�- •-- - - Sewage odors detected when-arriving at the she:(yes or no)_ revised 9/2/98 Pate 6 of It SUBSURFACE SEWAGE DISPOSAL SYSTEM pVSPECTION FORM j ,_ • ; PART C SYSTEM-INFORMATION(continued) Property Address: Z 33 /�/2t 5i S/Q G 6- �V, �N-00,)C c2 Owner: K A/ ~2G :.: . inspection: v G-UGGC /3 G ' ' BUILDING SEWER: S/3" f (locate on she plan) Depth below grade: Material of construction:_cast Iron_40 PVC_other(explain) Distance from private.water supply well or su tion line Diameter Comments:(condition of joints,vegting,evidence offaakage,-etc.l SEPTIC TANK:— (locate on site plan) Depth below grader&-apr>` Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(expiain) If tank Is(petal,list age_ ls.age.confirmed by Certificate of Compliance_(Yes/No) Dimensions• Sludge depth: _ Distance from top of sludge to bottom of outlet tee ortraffie: 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 dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level In relation to outlet Invert.-structur". tegrity, evidence of leakage,etc.) , AAJ V-N fs �L� TSN )� SHO�LO �i C 2E�i.�A C E7 GREASETRAP: (locate on site pian) 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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquld.level In relation to outlet invert,structural integrity. evidence of leakage,etc.) revised 9/2/98 Page 7oftt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOfiM PART C ' :u SYSTEM INFORMAATiON(continued) Property Address: Owner: Date of Inspection: �'`�2✓t 1 CrUGG L�✓�� /L „ ' TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or at time of,inspection) (Iota a on site plan) Depth below grade: Material of construction: c'ncrete metal Fber lass Polyethylene other(explain) Dimensions: , Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Data of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX- ( (locate on site plan) • N Depth of liquid level above outlet Invert: Comments: (n'4�a If level and distribution is equal,evidenoo of solids carryover,evidence of leakage Into or out of box,etc.) — -— r5 oL1� ►4n1i� r gl,jA 9 A-, G- . EE c�E.-T Ovt:2 1�% U�a 1�y L% 'ro L-0 66-c- b S 5'1S'rF-—111 PUMP CHAMBER;V4- (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 appurtenances,etc.) revised 9/2/98 Page 8of11 i SUBSURFACE SEWAGE DISPOSALJSYSTEM INSPECTION FORM 1 PART SYSTEM INFORMATION(continued) `•� Prdperty adore::: 2 33 jZ- , 2C t✓-7,� y• f��aOvE2 ovtrner: K� (rc-• 6�'GG-E�v 6 E 2G-E 2 � ..:t ;ti- Date of inspection. SOIL ABSORPTION SYSTEM(SAS):(locate on site plan,if possible;excavation not required location may be approximated ated b n on(n trusve methods) n"x•� •. I' If not located,explain; Ty e: leaching pits;number:_ leaching chambers,number leaching galleries,number:_ leeching trenches,number,length: 4CC-6 a leaching f �- o Ids number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,et0- A f3 TFA^ krYs Sv CESSPOOLS: I (locate on site plan) Number and configuration: ; Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensioh's of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) Comments: (note condition of soil,signs of hydraulic failurerlevel of pond"mg,condition of-vegetation.etc.) PRiVY:4&-," (locate on site plan) Matedals of construcn: Dimensions: tio Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.) revised 9/2/98 Page9of11 SUBSURFACE SE1 VAGE DISPOSAL SYSTEM INSPECTION FORM • PART c SYSTEMA INFORMATION(continued) Property Address: e 7 N. f/N v ✓l;� owned• Data of kupection: . . . X131 g� . � . . - • . .SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least t*o permanent reference landmarks or benchmarks I locate all wells within 100'(Locate where public water supply comes Into house) • ® wed I o w��� i ,�r Q�I ✓it vn. J revised 9/2/98 Page 10orII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addr—: 2 3,:3 �v 2Es7 S (Lr�r iv• N�v�E/L • Owner: 114i2T 6-L)&&C : Data of ktspectiort: NRCS Report name Soil Type_ i Typical depth to groundwater I USGS Date website visited Observation Well checked i Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property.observation hole.basement sump etc.) - Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators.Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) C revised 9/2/98 Page 11 of 11 Town of North Andover, Massachusetts Form No. 1 NoRTH BOARD OF HEALTH 3�Oy�t�eo 616 �'YOL -i __j9 r. A APPLICATION FOR SITE TESTING/INSPECTION A�A�iTEO PPp`y(y �9SSACHUSE� Applicant K, , f3a`66,-t AME ADDRESS TELEPHONE Site Location__ Engineer. NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. 9g3 I S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. I BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: 41;4f9 LOCATION OF SOIL TESTS: ;? 3 fst- Assessor's map & parcel number: a ap )o(,rA P 2�c_� `7.7 OWNER: Hu Pte, .�ire/t� TEL. NO.: `77 . - ADDRESS: ;;1.23 .60es7- SiyrL`� ENGINEER: A)e, Ert,( 7;� c�,�.� TEL. NO.: q 7e '- 1. -t-7 G CERTIFIED SOIL EVALUATOR: -, , 2 Intended use of land: residential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. r � t AO �.�-�.: •`•'wt�A'+:'.`�:.�::x +.�... ly�' ';Y�+. 1�+�%.v.:.`..�•1:�~%��. y�,4 �',\y�L.•`":1,`�, �•�.' •,;`.l. �: �. .t,i'r'_."o��` �ti�'`l'•'-.�;��:��'L 1,,, �r..�'�" '`����' t�� 'T t�-`4:...;C� .'.t�-•h%�a'..'�' . ti- ;�.i.i'`.< <:� ''�' .1 �} '�:j�.v.ia '-� ♦tw,..t:l'�.•� ..�`� •�.." ���t `•`''° �'C'i;L. r L'.f•� =4�.�:1 y`��,�y��.,,.,��x�.�� t\' '2`.• ..;,�y_ '1T�.ficT.,`rl 1:`` -�.• .��,.1'.ti i•:•'�. _�y'. ..�1`+��J%� -.:"�y i`� `�y!' xy':i�� ~ � - ��� �h'..�� �1`!`L>r�j�'.?'_•,�. ."`C� 1, .\� �i � ` "v.2 `".�.��-\_ y`��: �.?tom .�4 W �_ �� Y.•.• �� \ •�l.'y' ���:. + �1i1,�� 'ir-"`�aC{y� ��'' -°"^_�';�"��T"�� �+r%•+�y'`�`t`tR�•��i=�1`'. � "�' v��l vx_ i- �.:p:;'. "�'+:._'J `t•�; ;`= 4�`" t � �,•y"� :Y Vy,�- i, ^..:,��4,;+....1F, qY• •+1� � 1�c i-.. '', y"� +,� S' .,„ V•il .c � q :13.17���N'T,....`r`r.yt ,.l:ct.'`'t� v...�f.:�Y �:tZM.��'�:��:.ii.. .:.�`nti;+'�.•;C...�: .�... ._ - .� %:�..��.;..�•''.�...•`.' .. .-w...�`-.� , w" �f� x i._"�; :ar�, -.T•2,�; �'��-a��"C t t,.-:.'.'..S^� �t�. ' 'ss'y�* ,�7" e4.�'-.'''3.,,ptr. �•G"� .x;a:�'"..t''r,��" „ - til . • . �, ;� �_ /f v OW; j k ii !I I(I 1 - 1i� •\ Ifl i 1 . •i ' I Ti? �-' - - -- - �v f Q . , S �.- � �S -- �-5 -- - -- is � ,� �. - ,�,- - - -- -- - --- - - - - - - ,� _ - - ..� - - - {.-. ---- �. - - FORM 11 - SOII. EVALUATOR FORM Page I of 3 r Date: e.Ilzfqq No. 7�1-2. 1 Commonwealth of Massachusetts , Massachusetts Soil Sui bilio, Assessment for On-site Sewage Disposal } C ..Q �o . .-_1. :. Date: Performed By: /� ".�a..n^.,.n_ ..... .. J Witnessed By: owner's Name. K U/2 I (suy� �NBFn(rc2 1.ocmion Address or 3 rp/ZL5 Address.and `°`" Telephone f /U- ew Construction ❑ Repair 97 - 6 8 Office Review Published Soil Survey Available: No ❑ Yes /q8/.............. Publication Scale /=� �..- Soil Map Unit bC Year Published JT- Drainage Class INe-L--d—.............. Soil Limitations Surficial Geologic Report Available: No ® Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) ................................................................................................................. Landform ........................................... ............... .......... ........................................................................................................ ................. Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ... ................................................................. Wetlands Conservancy Program Map (map unit) - .. .............................................. ....... .. .... .. Current Water Resource Conditions (USGS): Month "9-,p 1z Range :Above Normal ❑Normal ❑Belcw Normal Other References Reviewed: DEP APPROVED FORM•11/07/95 t FORM 11 - SOIL F,VALUATOR FORM Page 2of3 r Location Address or Lot No. On-site Review Deep Hole Number T Date: ✓r/3 J%�J Time: ���`�0 Weather Location (identify on site plan) IQ R3 t / Surface Stones �'^y Land Use Slope des%c�e��n�L M " Vegetation W"0'q -,O Landform f�s2o✓��� �a -�`E Position on landscape (sketch on the back) Distances from: Open Water Body /0' U feet Drainage way —'00 feet Possible Wet Area 9 4'a feet Property Line feet Drinking Water Well /3 0 . feet Other `— DEEP OBSERVATION HOLE LOG* Depth from :Soil Horizon �Texture Soil Color Soil Other Surface(Inches) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravr 3/ �o v,y%- crcn. 5`y 4-/3 meD �« Parent Material (geologic) C_C�IM1' eV_ --t1_11 _ DepthtoBedrock: g� Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: — Estimated Seasonal High Ground Water: DEP APPROVED FORM-12/07/95 t i � III FORM 11 - SOIL CV ALUATOR FORM Page, 2 of 3 Location Address or Lot No. 2✓2 0.5 1— S% 0 On-site Review Deep Hole Number Date: ����F �y Time: Weather J. Location (identify on site plan) Land Use 12e.nnf1_ Slope M Surface Stones /Y►Ati'y Vegetation cjo') CEO _ Landform Position on landscape (sketch on the back) Distances from: Open Water Body /000 feet Drainage way 011:10 feet Possible Wet Area 900 feet Property Line _5' feet Drinking Water Well x.30 feet Other _ DEEP OBSERVATION HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones, BoulGravders, Consistency, % Parent Material (geologic) low DepthtoBedrock: 3E' Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: V -- Estimated Seasonal High Ground Water: DEP APPROVED FORnI-12ro7195 I I FOIZM I I - SOIL LVALUATOIZ FORM Page 3 of 3 ..a Location Address or Lot No. a2.�2 3 Determination for Seasonal Hieh Water Table Method Used: ❑ Depth observed standing in observation hole _ inches ❑ Depth weeping from side of observation hole .. ... inches ® Depth to soil mottles .37 inches r, P, ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ........ Index well level .... .. . . Adjustment factor ................... Adjusted ground water level ........ ....................................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? u�— If not, what is the depth of naturally occurring pervious material? Certification I certify that on 1160 l 19 (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature / Date G �� DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page i of 3 No. Date: Commonwe Ith of Massachusetts ,Cfo ,�� , Massachusetts Soil uitability Assessi'nent for On-site Sewaze Disposal Performed By. ........ ........... l �� �J Date: . . .. . .. __. Witnessed B � �'`� _. -23 �T owner•,:Name.'je�/ .Z% �.�c3� ?l�� Lot A �O _L/JL� Telephone! -G Z � � (_ ew Construction ❑ Repair Office Review Published Soil Survey Available: No Yes Year Published 1� �...- Publication Scale �-��J, ��� Soil Map Unit � ......-.... Drainage Class ` !� /L�T� .................. Soil Limitations ......................... .. ............. Surficial Geologic Report Available: No Q Yes ❑ Year Published Publication Scale , . .....�. Geologic Material (Map Unit) ......... ...................................................................................... ............... -......... . Landform ......................................... ....... ............................. ..... . ... ........_ .....- ...................................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes KI Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No El Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) -.......................•.. ............................ Wetlands Conservancy Program Map (map unit) ........................................................................ Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal ❑Belo/ Normal Other References Reviewed: DEP APPROVED FORM•12/07/95 i i � I FORM 11 - SOIL EVALUATOR FoIzNj Page 2 of 3: Location Address or Lot I40. On-site.Re view Deep Hole Number ... ..::. Date:.. "/'.. �� Time:;./-5 Weather Location (identify on site plan) :... ..: . ::: .. ..::::_,...:.:::::.::.:. ..::..:.::.......:..:...:.: :.:. . Land Use Slope M Surface Stones /yf Vegetation ��./1»�. :. . Landform ... :...�^ .:..:.. � /its -.. Position on landscape (sketch on the back) .....: Distances from: Open Water Body����''U feet Drainage way zE'r1C> feet Possible Wet Area -�7� feet Property Line ..:.I .. feet Drinking Water Well%-'.. . feet Other ....:..: '..:.:..::::.:.....::.:..:. DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) g Z� �w o y� - D-AT EV ERY PROPOSED DISPOSAL AREA Parent Material(geologic) / ��p��— TL '-- DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: �6 Estimated Seasonal High Ground Water: .—..– DEP APPROVED FORJN1-12107/95 FORM 1I - SOIL L,VALUATOR f;ORM Page 3 of 3 Location Address or Lot No. c� T , Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole......... . ... inches ❑ Depth weeping from side of observation hole........... .. inches © Depth to soil mottles inches 7;P4''.2 ❑ Ground water adjustment .................. feet Index Well Number .................. Reading Date ................. Index well level ............ Adjustment factor ................... Adjusted ground water level ...................................... .............. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all r as observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? _ Certification I certify that on �S (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature( ate / DEP APPROVED FORM•12/07/95 i DORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review Deep Hole Number / Date:: Time: ` . Weather ��'� F GA!� Location (identify on site plan) Land Use Slope ( /o) -- Surface Stones /L/'�l�l� ... Vegetation Landform Position on landscape (sketch on the back) ...:. Distances from: Open Water Body feet Drainage way . . ... feet Possible Wet Area feet . Property Line ... ..... ... feet Drinking Water Well .:::... feet Other ...__..,..:...:..:.,...:.:.:::.:::.:.: DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) L r MnqlPlt0F2 ED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) DepthtoBedrock: _ Depth to Groundwater: Standing Water in the Hole: — Weeping from Pit Face: Estimated Seasonal High Ground Water: UEP APPROVED FORM-12/07/95 DATE.- LOCATION- EL:- ATE:LOCATION: BOH WITNESS. PEECOL-'TION TEST r B 0 TT•fvI DEITH 0 F PERC TEST: a '7 TIME OF SOAK: _�4 � ( � __ ("�� Ie�s'� � � minutes Icnc) TIME AT 12" TIME AT c" Z_ TIME AT 5 ` GVE�NIG�T S0 K TIME: ST�.rTED ' NE,`/\T T D,L" ` i "lJh v1 f IME I j.. , I IME "='T S TIME hl^T ES i f � ro rc� ;-7 -5777 BOARD OF HEALTH /�� TOWN OF NORTH ANDOVER, MASS. 1 �2ESCN7 �t�Np� ttoNS I�IuT 'So ir4OLF F-am Suesa2rpec. _ { w - a � 1. NAME C F'47?*e r%1 e: .lT•% :r b . DATE .��- ell- 2. ADDRESS .��.,;�-; .o�r S LOT NO. .��. . . . TELr..� . 3. NO. OF BEDROOPIS �3. . . DEN YES NO. . 4. GARBAGE GRINDER YES . . . . . N0. 5. SHOW DIIZASIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7, SHOW DIbENtSIONS OF LCT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM I.O. SHOW LOCATION OF BROOKS, STPEANS, DITCHES, LEDGE OUTCROP, ETC. 11, SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULAT IOIZ SHOULD BE READ CAREFULLY. C.�� r ...� K ,. . , . 1 i r t �� ,� �`// ' j r� " 1�` � //O �Cl—ES l ,� \i. a�` �� �— i . f � .. r "`` V+ ��� - � i 3� � .. _