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HomeMy WebLinkAboutMiscellaneous - 224 HAY MEADOW ROAD 4/30/2018 (2) 224 HAY MEADOW ROAD / 210/104.6-0078-0000.0 I J ��. i�� , a � 4 c �S�•02-28E ► �' 20,00 Ste. 554-27-10 E 217.23 i •3 Q� off` i G 67'00 565±42 d lk 7 `� LOT 14 A i 4 x,946 i � • of J J. / 4! 40 i �, DISTANCE / A S 1' = B 67` C 36' D 24 ,ox � ,. E 32` 16a - F 53' .S/+ PLAN SHAVING SUBSURFACE SEWERAGE DISPOSAL SYSTDO AS--BUILT ELEVATIONS "OWNER LOT 14A HAYMEADOWRpo CELLAR FLOOR 136°45 LYNCO REALTY TRUST � DWEl ET OUTLET 134.00 DATE 3-25-84 SCALE I=4C} ST MET 132.77 { ST OUTLET 132.52 PREPARED BY D'BOX INLET 132.42 b Dom-BOX�O]]U1LfT 132030 FL j(/q�j \/\'�j /f�/jEND �Vr.D �,��I 11,,SSC) �'f D ID NOTE I CERTIFY THAT THE SEPTIC WAS INSTALLED AS SHOWN, ' 0 000_ ,) HF'�RLAN •S N:'- R.-IFNL.rr, n Of: TFjr cy.5U, L{.` f —! 1 ...r .��4 7 4 1 ! '.' Iii' r' ?1 J �. i s s F z , C��e a�vs co�� of j'�•h f� =rte' I ire pc-� Gvij ! rT rel IPTG, G s fG�cj S c" r , _1 1 ;1f1�•1 1 Q S46'02-23 E Q" • e 0 ft 2Q()o 5, ar 91 p ! 040 S54-27-I©E Q h 217.23 i 6 :00 S6 .42:-?.? `..� m r t! , '. —, LOT 14A 041-,946 C- C)" f , V / DISTANCE A 51'. g 671 C 35 .� � a D 24 •Q,cs 2. E 32 . - v F 53 . -- PLANHoVVINSUBSURFACE sFWERAGE Dc SP05AL SYSTE N t AS--BU 1 L T ELEVATIONS. 1 LOCAT1'vN L07 14 A NAYMEADO 1�` FU . M-um FLOOR I3 s ;OW NE R LYNCO CU REALTY TRUST 0W`ELLSNG OUTLET 134,o0 DATE x-26-84 SCALE =40 ST INLET 132.77 ST OUTLET 132.52 PREPARED BY D-BOX INLET 132,42 , D-BOX OUIIfT 132030 FLK' ENO FIELD f 31.95 NOTE I CERTIFY THAT THE SEPTIC `AW-S INSTALLED AS SHOWN, ry f-)f_, h'.}ti,P`i �`j i'1,� ifci r hi✓�4 r+,_ ,� Y,l.r', -.� � ''� ti£ �#:pct�',` j 5 -, r.'+ _ __ i I r t * I I I NEW ENGLAND ENGINEERING SERVICES INC TOWN OF NORTH AN©OJER/ SOARD OF HEALTH Fa00 Mg February 15, 1999 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, NIA 01845 RE: TITLE V REPORT 224 Haymeadow Rd Enclosed is a copy of the revised Title V report for the above referenced location. The system passes our inspection. If there are any questions please call me at my office, 686-1768. Yours truly, Be amin C. O �odr., .T. President I 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 t I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Cornnuss;oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A U j� / CERTIFICATION r (� Property Address: ✓2 t H�`�in��G�.r v Kb� ;?;2Name of Owner—EP-,:C�� bo Address of Owner: .? t lc ,Mcc c�u 12cC, ,t,%- Date of Inspection: z Name of Inspector:(Please Print) Benjamin C. Osgood, Jr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) CornpanyName: New England Engineering Services Inc. Mafng Address: 33 Walker Rd. , Suite 219 Nnrt•h Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: s s e s Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails /� Inspector's Signature: L ./ Date: 41 The System Inspector shall submit a copy of thibyinspection report to the Approving Authority(Board of Health or DEP)within 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 ofl-EnvironmentM Protection. The original should be sent toZfm system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page IofI] `: Printed on Recycled Papr, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �2 l 14, vnCG.c�i w n ° Owner: Date of kupection: 21 1.3(��t INSPECTION SUMMARY: Check A, A C, or D: A. SYSTEM PASSES: 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 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. 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 inspection;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 pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumphig-Tnore than four-times a yeardue to broken or obst, cted pipe(s). The system will pa— inspection if(with approval of the Board of Health): -- broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � �y til�•�rr ec� '� ti A} Jo ,of Owner: / Date of Inspection c� ,>c•;c di t3.. L .'-kc"j C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH_WILL.PRQTECT THE PUBLIC HEALTH.AND SAFETY AND THE ENNOBONMEhLT: 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 IS 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 than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/95 P2ge3Of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A j CERTIFICATION(continued) Property Address: 2Lj H6tj mt�.d�,�,. l Owner: GJ,nJcn p � Date of Inspection: 1; C L•rr a.V) 0. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into 4ecifity-or-s7sMm component-due tto en overloaded or,69gged SASvr•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. I Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for —coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: j The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: i Yes No the system is within 400 feet of a surface drinking water supply the system is-within 200 feetof-4-i++lgutary4oa a vfooadrir,kir►g water-supply -- ---• -— - the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office of the Department for further inforgiation. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No / Pumping information was provided by the owner,occupant, or Board of Health. None of the system ecompooents.baw.13ean poatpad+tor-0Jeast two xruaakc and-ihe'rystsm hasbwoascaiaiwgwwsal Clow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 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. V _ All system components,excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. I The size and location of the Soil Absorption System orr the site has been determined based on: Existing information. For example, Plan 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 land.occupanu,if different from.owner).were,provided.with thAproper—main—a•" ^f SubSurface Disposal Systems. revised 9/2/98 page 5orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Insfon. (C n 2I 1 ATI FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. -.Number of,bedrooms Idesign): -` Number of bedrooms lactual)c -' Total DESIGN flow Number of current residents: ) Garbage grinder(yes or no):�.cj Laundry(separate system) (yes or no)d!-0: If yes,sepacateinspection required _ Laundry system inspected (yes or no) Seasonal use(yes or no):-IL/0 Water meter readings,if available (last two year's usage(gpd): Sump Pump(yes or no):- L� Last date of occupancy: et—Ir �f COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) 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 5 system: lyes or no)_ Water meter readings,if available: - Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: L es2S 5E y System pumped as part of inspection: lyes or no)4e J If yes,volume pumped: Zlo- gallons Reason for pumping: l)C 7-0 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 cl c9,2 APPROXIMATE AGE of all components, date instaNed{if Ictrownl•end source ofrnfametron: -•---�- -- •• — - - - - Sewage odors detected when arriving at the site:(yes or no)/zo revised 9/1/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) �Y Pr Address: 2 2� I-'t��m e G.c - c�... (�`U N �^��•,_1.,� Owner: n Date of Inspection: BUILDING SEWER: (Locate on site plan) r. Depth below grade: ( Material of construction:_cast iron W 40 PVC_other(explain) Distance from private water supply well or suction line Al Diameter Comments: (condition of'oi ts, ventin , evidence of leakage,etc) l r ✓ t ✓r Q. 4 C 'D':; Q, r SEPTIC TANK:_ (locate on site plan) I r. Depth below grade:17H Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is Inetal,list age_ lss.age.confumed by Certificate of Compliance_(Yes/No) Dimensions: c'`J Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ p;ItleCe- c',2ej111E/ 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:alei.Sc;2 SL—J"K Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles,depth of liqui levg!in relation to outlet invert, structur&Hntegrity, evidence of leakage,etc.) '7T4h r-� O/� cc��c • ]� Ct/I GREASE TRAP (locate 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z [ �c-• rrr ems ;.,, {�5� 1 {�^c�c, Z Owner: C('� Date Of Inspection: 2113)�� v �1,, TIGHT OR HOLDING TANK:/ (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: nn Comments: 1 (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — - — PUMP CHAMBER-,&/4 (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 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z Z LI cj yY>('cr ..,, � I Owner: r Date of Inspection: z) 61<<c, SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: L/ leaching fields, number,dimensions: / jlj�e/do -700 S / �• �� Gs - bu. overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, si ns of hydraulic failu e, level of ponding damp soil, co dition of vegetation, etc.) O 1,-e,( c'c pi) J 1917e. zle -S :E'775 7 r js - CESSPOOLS:,&i (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(cesspool must be pumped as part of inspection) 0 Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of-vegetation,etc.) _ PRIVY: (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Plige9OfII f i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 Z q Owner: Date of Inspection: k -ca cQ 0-,,,I., r k e„1 Z) t3 17,t SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I I nn I N �5 I V--ft ti GEE) E) revised 9/2/98 Page 10 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property Address: 2-29 � ' k).f}/V.0 C� 0 CZ- Own": Date of kespection: Z1t31�a NRCS Report name S Qi 1— S0(Z 0 eel t u` K C*0 V�✓t-�S Soil Type_ C a n to✓l Typical depth to groundwater USGS Date website visited z Observation Wells checked Groundwater depth: Shallow Moderate X Deep SITE EXAM Slope j: l)az Surface water ti` Check Cellar Shallow wells .-I J 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) � v i Ste• Com.-,�t'��, 1�:�� I T C-4 C. revised 9/2/98 Page 11 of 11 � t NEW ENGLAND ENGINEERING SERVICES INC OV March 17, 1997' North Andover Board of Health Town Hall Annex 148 Main Street North Andover,MA 01845 RE: TITLE V REPORT Enclosed is the Title V report for 224 Haymeadow Road,North Andover,MA. The system passed the inspection. If there are any questions please call me at my office,686-1768. Yours truly, Benjamm C.Osgood Jr., .I.T. President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 k C7 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Wllllam F.Wold Go.wmor Trudy Coxe Argon Paul Celluccl $1C1tary tt Govsmor Davld B.Struhs Cotnminioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 2-2-Y /�� yyJ�/9 00� f2 D Address of Owner- Date of Inspection: 3/J/V-T (If different) Name of Inspector. Benjamin C. Osgood Jr. Company Name,Address and Telephone Number. New England Engineering Services, Inc. 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ,Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: /) Date: f7/ The System Inspector shall submit a copy of this ins ion rep to the Approving Authority within 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 report to the appropriate Pim system owner shall submit the Po pp priate regional office of the Department of Environmental protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yea, 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, 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 Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292.5500 A %J Printed on Recycled Paper 1 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z 21/ pirl y,—jFof_4 v..v 2 0 Owner. V A k V R N f V C Date of Inspection: 31 31q 7 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(.) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution bar is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEN'fi Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The _ system has a septic tank and soil absorption system and is within 100 feet to a surface water supply 1 or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddress 2211 t-t H Y n,►F A ip a, 2 0. v. AV 0 C ,/0 2 Owner. Date of Inspection: A L V #+A)i N C V 31 G i'� Dl SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. AC Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. L✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tunes 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. off Any portion of a cesspool or privy is within a Zone I of a public well. ,Y Any portion of a cesspool or privy is within 50 feet of;a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply I the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(MPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECELIST Property Address: 22 4 Vt4%Y.,u E A to o -✓ 2() �! ,qA)Oo Jr 2 Owner. V RL- V AN w e N Date of Inspection: Check if the following have been done: ZPumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates /during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. V As built plans have been obtained and examined. Note if they are not available with N/A ZThe facility or dwelling was inspected for signs of sewage back-up. V 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. 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. V^ The size and location of the Soil Absorption System on the site has been determined based on®sting information or approximated by non-intrusive methods. ,/The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. 4" SAl 7 ,J n D E et S r p 1­7 C TrvN)( YEN O O- B k (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 Z y t-to`t nn r A D (Zp Owner. V41- V A ti tN r.✓ Date of Inspection: RESIDENTLriL; FLOW CONDITIONS Design flow' gallons Number of bedrooms:—.61— Number edrooms:—.Number of current residents: Garbage grinder(yes or no):,4!PS Laundry connected to system(yes or no):"f'` Seasonal use(yes or no):�/1 `�— Water meter readings,if available: Last date of occupancy:c T rt ti COMMERCIAL/INDUSTRIA U " Type of establishment: Design flow:------gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)-4:e i If yes,volume pumped: i.57c v gallons Reason for pumping s, k,-)S o TYPE 0 'SYSTEM i/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: Q l q S 2 Sewage odors detected when arriving at the site: (yea or no)A/ (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 2 2 0 0 v R D, ,/�.,J Oe✓t/� Owner. VOL. V A/V 1 N G✓ Date of Inspection: 3[►3 15.7 • SEPTIC TANK:_ (locate on site plan) Depth below grade Material of constriction:le-111ncrete metal_FRP—other(explain) Dimensions: i SCJ V !;-A i[.c,.v s Sludge depth.___(, Distance from top of sludge to bottom of outlet tee or baffle: '- Scum thickness: 4/,i Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to�3tlet invert,structural integrity, evidence of leakage,etc.) TrA'V t e5 "'e7 ffI-L✓ Cc)Uef2ea A V fi 7OZZ QF•c K ,SO i/-f6= iN tr'r .4n/J? o✓TL.G'T TEElf W C >.✓s PF c f w-.-I us IW 4 r4 ivt i/1.40 2 Tr'G L c,n is !> K Fi o"T7-,o t- 7-.4A///% fl*f O !i- «T -- e� 12;/17- Ig-10 6121,eXs 7-�JA•r HAo 1!-,4t.j_E.v i.t/ GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal FRP other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addreaw Z 2 N H,4 Y t/+DZ� �}N o c Owner. V FE 1, v r?) V Date of Inspection: 311-31 cl7 K TIGHT OR HOLDING TAN _ (locate on site plan) Depth below grade: Material of constriction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: ¢allons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) 0y( ..`A-, O C2 A� /'",N Docl Oec t, Sc7 )Ns PEcTE�_ NILE LA-/Pr-';- 00 6r- itiT"D THC STG.vc C>rf Tk� i o "11-1E SiL.�C /Is 02 Y' PUMP CHAMBER_ (locate on site plan) Pumps in working order-(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addrem Z 2 K R-0. .V. R•t%P 0 v E 2 Owner. \/191. V 14,V 1 ni L,✓ Date of Inspection: 1I SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type leaching pits,number._ leaching chambers,number._ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ► Ff G LD overflow cesspool,number: Comments: (note �condition off soil,sips /�of hydraulic failure,level hof ponding, lcondition of vegetation,etc.) ,�n' c z '900 Spit. CESSPOOLS:_ (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(cesspool must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION(oontinued) Property Address: Z 2 ��y v+.<<.� Q-� /V. Owner. �g1J�Ci v e�2 Date of Lugmotiou: V cx t U c n+ ✓1 a V 3� 13�qry SKETCH OF SEWAGE DISPOSAL SYSTEM: inelude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Hu�,sL L 1047 p �t�GP Gr Pcc,�- 9e<K W 4 i-U c a716 A.; `,F Cep J PC L' HGL� LERci-� l3r'� DEPTH TO GROUNDWATER Depth to groundwater. L—-7 feet method of determination or approximation: b c (revised 11/03/95) 9 OF NORi 5 OFFICES or- gown of 120 Main Street o APPEALSNorth Andover, . NORTH ANDOVER lit III.I)ING Massachusetts0l84 CONSERVATION ssACHUS, DIVISION OF (617)685-4775 HEALTH 111—ANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.11. NELSON, DIRECTOR Yc� (U7 A �t—(Gtc,1wtUGLv TO 1 K VV Ne c. Lr,1 ��, ��i����►-��{ w t —k G\J 1 �. TkC� 1 � NO wy t NpRTM a ?o`t ``DBOARD OF HEALTH A ^G 120 MAIN STREET �9SSACHUSEt�y NORTH ANDOVER, MASS. 01845 TEL. 682-6400 (�v , l , .--, MrArCk ZZ( lgff re : to r (y A 1-1 n w►c:;;dow r i 5 o� c k6los ho qG�c T�c pts, (� Tti� ?(� 7G .�J � �'�►'��C Q � l T l5 Ss I t w Y10( I Vert&rC&f-e LA-) c 1 j t✓e�re °F pIORr,, r OFFICES OF: 03 °m Town of 120 Main Street APPEALSNorth Andover, NORTH ANDOVER BUILDING ' Massachusetts O 1845 CONSERVATION @a1CN^ DIVISION OF (617)685-4775 HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR /''" t•G P I� � -' � 1 Z7�-1 l-�►c'W0�6cs.,� Tke prop-^.-txed p:'01 5kcA-Ad- 6e ( Vnlc" It'nSZ'G,( ( c j Gcs j cam►c�r�t -C 6(}ept �i cp . M • ;, � CD ��Si cam. o AQUA DREAM POOLS inc JOe 2 2�� 1-f�� p a�►°`�' r lg—A A9UAbREAMPOOLS Custom Design • SPAS • HOTTUBS • SAUNAS • ENCLOSURES 1211 OSGOOD ST. (Rt. 125, P.O. BOX 266) 2 c NO. ANDOVER, MA 01845 DATE 3-zZ'�`O Service Department (617) 689.3399 SCALE PHONE ..........................................:..............:....... — —— i ...........:..... ........ ... ................................: ........... .......................... .................... ...... ...... .. . _ ...:.... ...: ....:.... .... ...:.............:....................... .....:..............:......... ............... .... .... ._... ......................... ....... ...... ...... ...:.... ... ..................................... r� . ........ ......... j 4 ....:..... )/ i f ( I 0 .......................................i..............i..............i............... ...... .... ...... ...... J ..........:....... ......................... ..... .... .... . ,° . � ...:.... ... ..........:.... c . : . ......:.... : s- ..........................o — ..... 1•� ii i 0 -is \'. QK L y .,..,. .:... .. .. ..................... . ... . NZ .... .. . c> Y .... ...... �, ..... ` .. .. ...... ...... - ' ) ..... .. ........ .... .........................R....... ........? .............................. ................................ .. .. ...._ ...... . ......... ..... . .. ........ ...... _ ... ....... .... ..... .... 1 , � . ,.. } ) • A:- i . .� --{ �t� �l�` 1 n� . �?1�JG ..... . .: . .... a . :.:. CVX SUPE IOR 10" 0 CONCRETE WALL • VINYL LINER P0, LS f'.,•-rd of I-rc!_,lth . 1—tl•. 1�n�tier,1:ass SUBSURFACE DIE'OSU DESIM CITIECK LIST LOT 4 APPROVED DATE DISAPPROM DATE Provided: Reasons: T t e Reg 2.5 e submitted plan rast 611olr as the lot to be nerved-area,dip,-asienq lot #,ahatters ovation and log d cp obse -ation. holes-dist€mee to ties location sad re-salts pamolatiom tests-distance to tics d design calculations & calculations clwieing require4leaching zria location and dimensions of syrstem-including roBerve area existing and proposed contours ( location my wet areas ultl-An 1001 of seirage disposal system or disclai=ar-check watlands mapping ( ) surfcce and aubsurfaco dxs -,d gain 3,001 of sers,ge di.aposel vystsm or disclaimsr ( ) location any &ainage eage�*-,its iAthln 1001 of am s o dicposal syst€m or discl.aiK-re -M-aging Board Me.s Ion-ova sources of -v:r to supply vi chin 2001 of s&--:age cli:poral syste=m or disclaimer location of Proposed ll to serve lot-10I from leae i.ng facility �location of water )des on property-101 fi;om laaching facility location of bend k drivevays o garbage disposals no PVC to be used in eonstruction r (q) profile of s6tsm.-ol evati ns of basersnt, plurpb, pipe, sePti.c t&rk, 6i stribution boss inlets and outlets, eictribution field pip#ng and btrcr elevations ( r�$ ft Fn g���rad i-�ter elevaUon in c-c:a sc-f,: e rUe-.csal system s) plan u-ist be pra ared by a F.3g d4ovr or other prof eSE:Ion-!42 ts=athori.zcd by lair to pa spare st��h plans a Rc,g 6 ��.:�S.._�.� :�ic Tanks {a) -CA—WC-, % of fl-ow., F =_ter talale, tees, depta of teas, access, Wiping C."Kle.,.mout I01 from cellar i;all or f ngr-oim- d a;.; o:-4zg pool ' (d) 25+ from subsurface Reg 10.2 I?astribution Foxes s2ope greater than 0.08 Reg 20.4 (b) stmp S.ibst1_rfae'e Dznif-n Chock I f st Pave 2 .. . FAIL OR , Leaching Pits . Leashing pits are preferred where the installation is possible Reg 11.2 a) calcula ions of leaching area-ninimm 500 sq ft ! 11.4 b) spac 11.10 c surf a drainage 2% j 11.11 d� cov -material e) 2E 140 splash pad f) tee at elbow g) no beds inpipe from d-box to pipe Leashing Fields Reg 15.1je) no gsreater t z�a� 20 Wmutes/inch � area- imm 900 sq ft 15.4 construction of field 15.8 ' �wface dx age 2 % 3.7 201 from cellar inn or inground GidmrUng pool j Leachingehes Reg 14,1 a) c' cl ons 0 eacbing area-min 5b0 sq ft 14.3 �' b) spa c -4 ft min 6 ft with reserve between cn lh.4 c) d - cions d) c traction 14.7 a) e 11!.10 f) �rface drainage;® 2% r r Da tzhi .1. Slope sTopa y x -- (to be s.o-inz ) b) y/x X 150 (to be sho-,,n) - Pus Reg 9.1 a) apron 9.6 . b) star by powar i fI I NORTH Aid DOVER BOAI�D Or i ;ALi'H I Jl�, 1 — r DISAPPROVED DATE TIME RE SON pAOV ED D4TE PROVIDED 17_. 9 6l� • Tit e 5 Re 2. 5 FaiVOKe bmitted plan must show as a minumum:ghe lot to be served (area,dimensions ,l,ot #,abutters) Planning Board -files) (,b) location and log of deep observation holes-distance to ties L. (-c) location and results of percolation tests-distance to ties (d) design calculations & calculations showing required leaching area (e) location and dimensions sf system (including reserve X area) / f existing and proposed contours of g) location of any wet areas within 10k wetlandssmappeng disposal system o t- disclaim (�} ) surface and subsurface drains within 100 of sewage disposal system ordisclaimer (i) location of any drainage easements within 100' of system or disclaimer (planning board sewage dirsposal / files) known•- sources- of__hater supply within 200' of sewage disposal_--system: or_ disclaimer - (k)- 'Iocation- of any -proposed well to serve- the- lot (100' from leaching facility) from. leachii (s1 ) -location of- water lines on property (10' facilities) (m) location of benchmark n' driveways o) garbage disposers A'p no PVC is to be used in construction q� a profile of the system (elevations of basement , plu pipe septic tank, distribution box inlets and outlet- distribution. -field piping and any other elevations) r) maximum ground water elevation in area of sewage dis system b a Professional Engineer or (s) plan must be prepared y other professional authorized by law to prepare sucY plans Reptic Tanks Rem. 6 / (a) Capacities - 150% of flow, water table , tees , depth . of tees , access , pumping, �(b Cleanout / c 10' from cellar wall or inground swimming pool d 25' from subsurface drains t _ � '- ^- ,��ilvK t�ribution Boxes -f iii -- — g. ( a) Slope greater than 0. 08 g.10.4 (b Sump Leaching Pits Leaching pits �aref` eferred where the installation -is possible 8.11 .2 (a) Calculations of leaching area (minimum 500 S.F. ) E.11 .4 (b) Spacing ,7.11 IC 1,c Eurlface drainage 2% x.11 .11 d /Cgvermaterial f ec cr Glb0,j aching Fields �� x.15.1 a) ':Greater than 20 minutes/inch x.15.1 ,b Area" (mi .- nimum900 S.F. ) x.15.4 �'c-� Construction of field D-.15.8 L °`d Surface drainage 2% 3.7 (e 20' from- cellar wall or inground swimming pool P Leaching Trenches k (a Calculationsof leaching area (min. 500 S.F.) ? (b Spacing (4ft. min. 6 ft. with reserve between): ;.14.11 -(c Dimensions 14:5 T.14.6` =- - (d _:_Cons:truction .14.7 = (e -StArie I ;.14.10 f) 4Surface drainage 2% Dovjnhill Slop6e �a) Slope y/x to be shown) ; b) y/x 150,. _ �to be shown) Pumps 9.1 (a App/-by ly.6 . (b� Stapower !; ! I t; - I! i - i - I i i Board of Health - North AndoverzHass SEPTIC SYSTEM INSTALLATICK CHECK LIST LOT'j .L P OVID DA `g` DI PRAVATI Cid OK L �' .I 1. Distance Tos a. Wetlands �ev�clfJ fc�i'itG b. Drains c.. Well 2. Water Line Location 3• No PPC Pipe Septic Tank ile�05 a. _Tees -_Length Ec To Clew Oat Covers. • b. Cement Pipe to Tank- On Both Sides of Tank Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flog 6. - Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clem Double Washed Stone 7. Leach Pits a. Dimension b. Stone D th c. Spla Pads d. T e. mit Pipe to Pit - Both Sides Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection r 1.0. Barricading Covered System w 11*! As,Built Submitted Lot Location b. Dimensions of System c. Location -4th Regar&to Pere Test i d. Elevationa ' 1 Water Table �. T \ I