HomeMy WebLinkAboutMiscellaneous - 224 RALEIGH TAVERN LANE 4/30/2018 (2) 224 RALEIGH-1 AVLKN UANt -
210/106.C-01040000.0 �n Lane
i
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�L\ Commonwealth of Massachusetts '_" p
City/Town of
System Pumping Record lmsllm�a—�
CT 3 0 2009
Form 4
0 D�PARTM DOVER
DEP has provided this form for use by local Boards of Health. Other fo used, but the
information must be,substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or-othei•approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of hous Ight rear ft rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State J 9�_-P�-1,de
Telephone Number
13.1Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2--No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of System: J _ /J V
Y 1,oc��
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L.S. Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
IL
Commonwealth of Massachusetts
City/Town of
System Pumping Record V Mil
Form 4 TOWN OF NORTH ANDOVER
41M s
DEP has provided this form for use by local Boards of Health. Other f HEs�-ri bD ,�T
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/"t rear of hou eft/right side of house, Left/
Right side of buildin Left/Right front of building, Left/Right rear of building, Under deck
Address n`
City/Town State Zip Code
2. System Owner:
`l
i
Name
Address(if different from location)
City/Town State Zip Code
'? r-,S- 50 a
Telephone Number
B. Pumping Record
1. Date of Pumping Date�t / vseptic
Quantity Pumped: GallonsfSao
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Wk C -2KA
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ntents were disposed:
G.L Lowell Waste Water
SignAtufe cfHauleU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
a System Pumping Record i 2010
Form 4 NOV 6
„M by`e
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Ot er TP0bu the
information must be substantially the same as that provided here. Before using Mis form, crieck with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: tiouse, right front of house, left side of house, right side of house, Left
rear of hou , right rear of hou-sb, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner: UA V` p
Name
Address(if different from location)
Citylrown Sta(D � —�7jpjQode
Telephone Number CJ
B. Pumping Record
c.
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition!of System: v\-
6.
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Loca ' ere contents were disposed:
L.S. LgWell Waste ate
-�_
Signa re o a er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
ssachusetts
Commonwealth of Ma
City/Town of
System Pumping-Record Nov '4 '104
Form 4
TOVvN ur n 1P:rH AN �v
HEA
DEP has provided this form for use by local Boards of Health. Oth r forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Le Right rear of ou , Left/right side of house, Left/
Right side of building, Left/Right front of building, Le /Right rear of building, Under deck
Address ® , �A~, AA
�►`r(Jv��(.��
City/Town l.� State Trp Code
2. System Owner.
Name'
Address(if different from location)
Citylrown - Zip Code
State
X73 If
Telephone Number
B. Pumping Record
1. Date of PumpingDate2. Quantity Pumped: '
Gallons
3. Type of system- ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yews No If yes, was it cleaned? ❑ Yes ❑ No;
" 5. Condition of stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' ere contents were disposed:
C'�.L S. Lowell Waste Water
Sign HaulejU Date
t5fbrm4.doc-06/03 System Pumping Recons•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record Fmnv
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use,by local Boards of Health. Other f s e
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Lefti ar of hous Left/right side of house, Left/
Right side of building,Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State
r
Telephone Number ✓—
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condit'o of Sy Ltem: (d2
6. System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
SignAtufe qf Haule Date
t5form4.doe-06/03 System Pumping Record•Page 1 of 1
SUMMARY OF INVERTS BUILDING TIES NOTE
SEWER ® 'FDTN.' 97.52 13" OFF BLDG. CORNER A B C .d Eo* THIS FLAN & CERTIFICATION 1S NOT
SEPTIC TANK IN- .97.12 SEPTIC TANK OUT 29.0 — 13.0 A WARRANTY OF THE SUBSURFACE DISPOSAL
SEPTIC TANK OUT 96.86 PUMP TANK — — — SYSTEM. IT IS A RECORD OF THE LOCATION
DIST. BOX IN 88.14 DIST. BOX 30.0 45.2 -_j AND ELEVATION OF THE EXISTING SYSTEM
DIST. BOX OUT 87.97 COMPONENTS.
INV. IN CHAM. 87.90
BOTT. CHAM. 87.28
"I HEREBY CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL;
EXPOSED COMPONENT COVERS ETC., SHOWN ON THIS AS—BUILT SUBSTANTIALLY
AGREE WITH ,THE APPROVED -PLAN AND HAVE DETERMINED THAT THE BREAK
OUT ELEAPPLICABLE, HAVE BEEN MET."'
APPRONS.
NEMCt1ENOK m
CIVIL
"l d dY-(�
S \ GNER DATE
s$lONk.SND
170.21'
s.o2'
tti" 1 Mr,DEC,=1
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a
LE/ACN Rub
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CHAMBERS (1i-20)
,VENT 29
Mr.PORT tp lw
s'p00 L} t� I=CAL
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are
IR,PROPS
CLEANW
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� AQ1p ..
LOT 4.3 c^ x d ; a NGti6F8?S:
(48,325 S.F.) s ler tip;
a
Co CHO
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1
i
.. 135.00 F y
RALEIGH TAVERN LANE
AS BUILT" PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MASS./332 RALEIGH TAVERN LANE
AS PREPARED FOR ,
DAVID ANDERSON TM: 107A
DATE: 5-04-12 JUN TL: 130
SCALE: 1"=40' TOWN OF NORTH ANDCOVEp 0 20 40 80
i1EALTH DEPARTMENT
MERRIMACK ENGINEERING SERVICES -�
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
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KAMINSKI
- No.29031
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Town of North Andover
'+�;•�, o::s'•' HEALTH DEPARTMENT
s'SACMUSt
CHECK#: DATE: /0///1-1P
'w LOCATION: V
H/O NAME:
CONTRACTOR NAME: !'
Type of Permit or License: (Check box)
O Animal $
❑ Body Art Establishment $
1
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑. Septic Disposal Works Installers(DWI) $
❑ZInspector $
❑ Report $ L/.
❑ Other:(Indicate) $
L Health Agent Initials
White--Applicant Yellow-Health Pink-Treasurer
r
TOWN OF NORTH ANDOVER NORTH '
Office of COMMUNITY DEVELOPMENT AND SERVICES oro'y�
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36 `►"9 . .r
NORTH ANDOVER, MASSACHUSETTS 01845
ACMU`�
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORM TI N r---
ADDRESS: o2O2 G` kG{,0e#AP: LOT:
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
❑Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation—Feb 2006
Page 1 of 6
t
TOWN OF NORTH ANDOVER NOR*h ,
Office of COMMUNITY DEVELOPMENT AND SERVICESa°O0
HEALTH DEPARTMENT
1600 OSGOOD STREET;.Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845 9SS"CHUgES
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
❑ 1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ 24" inch cover to within 6" of final grade installed over
pump access port
❑ Water tightness of tank has been achieved
Visual testing
❑ Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT TECHNOLOGY
❑ Type of treatment device:
❑ Installed per manufacturers requirements
❑ All components working in accordance with
manufacturer's requirements
Comments:
Wastewater System Documentation—Feb 2006
Page 2 of 6
1
NOR*�
TOWN OF NORTH ANDOVER ,
Office of COMMUNITY DEVELOPMENT AND SERVICES or�`.;' .. `..°�° °�
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845 "Ss;;C U t�
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
D-BOX
Ins ( pumped
on stable stone base
V
let tee if umped or >0.08'/foot)
ydraulic cement around inlet & outlets
[Sbserved even distribution
peed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM
❑ Bottom of SAS excavated down to soil layer, as
provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
1
❑ 3/4-1 /2" double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ Laterals installed and ends connected to header
❑ Laterals vented if impervious material above
❑ Orifices @ 5 & 7 o'clock positions
❑ Gravel-less disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
Retaining wall boulder/ concrete /timber/ block
❑ Final cover as per plan
Comments:
Wastewater System Documentation—Feb 2006
Page 3 of 6
TOWN OF NORTH ANDOVER AORT#t
Office of COMMUNITY DEVELOPMENT AND SERVICES ►°3 `i,�.o a°n
HEALTH DEPARTMENT WIMEW
1600 OSGOOD STREET; Building 2-36 ", .,.A
NORTH ANDOVER,MASSACHUSETTS 01845 "ss"
ACNUS
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
PRESSURE DISTRIBUTION
❑ -- inch manifold
❑ laterals installed with end sweeps
size:
material:
❑ Squirt test ft in height
❑ Equal distribution to all laterals
❑ orifice size inch as per plan
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Comments:
I
I
Wastewater System Documentation—Feb 2006
Page 4 of 6
f
TOWN OF NORTH ANDOVER o�NORTN ,
tiOt0 ,6 N
Office of COMMUNITY DEVELOPMENT AND SERVICES ►°3r "y _ '°'gip
HEALTH DEPARTMENT
1600 OSGOOD STREET;Building 2-36
NORTH ANDOVEpp MASSACHUSETTS 01845 �igSS~ 5 �
1� ACHCMU
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Tank SAS Sewer
❑ Property line 10 10 --
❑ Cellar wall 10 20 --
❑ Inground pool 10 20 --
❑ Slab foundation 10 10 --
❑ Deck, on footings, etc 5 10 --
❑ Waterline 10 10 10'
z 50
Private drinkin
❑ g well 75 100
❑ Irrigation well 75 100
❑ Surface Water 25 50
❑ Bordering Vegetated Wetland ,
Salt Marsh, Inland/Coastal Banka 75 100
❑ Wetlands bordering surface
water supply or trib. (in Watershed) 150 150
❑ Trib. to surface water supply 325 325
❑ Public well 400 400
❑ Interim Wellhead Prot. Area
❑ Reservoirs 400 400
❑ Drains (wat. supply/trib.) 50 100
❑ Drains (intercept g.w.) 25 50
❑ Drains (Other)Foundation 10(5) 20(10)
❑ Drywells 20 25
' Suction line 222(2)
2 1.00 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02).
s As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland
bylaws
Wastewater System Documentation—Feb 2006
Page 5 of 6
TOWN OF NORTH ANDOVER Q NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES o:6°y?��. °�
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 3"ss";C U t�
Susan Y. Sawyer,REHS/RS 978.688.9540 Phone
Public Health Director 978.688.8476—FAX
SYSTEM ELEVATIONS
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
Wastewater System Documentation—Feb 2006
Page 6 of 6
o�.NO oT: '3, 6 7 8
C9F
V Town of North Andover
HEALTH DEPARTMENT
UStt
CHECK#: DATE:
LOCATION: fj,`h e r LJ4 , N A
H/O NAME:
CONTRACTOR NAME: (-)`T' � L N
Type of Permit or License: (Check box)
0 Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
s
SEPTIC Systems:
II
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
Health Agent Initials
White--Applicant Yellow-Health Pink-Treasurer
AORTiq � Commonwealth of Massachusetts Map-Block-Lot
# 'q' co ' t -I 106.C-0104-
o '• �• Board of Health -----------------------
— a Permit No
i * BHP-2008-0222
.P North Andover
-----------------------
P.I. FEE
�SsA2 U1111€j F.I.
- ------------$1-25.00
-
Disposal Works Construction Permit
Permission is hereby granted Todd-Bateson
to(Construct)an Individual Sewage Disposal System.
at No 224 RALEIGH TAVERN LANE
----------------------------------------------
---------------------- --- ------ -----------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2008-022 Dated December 09,2008
--------- - --------
Issued On:Dec-09-2008 Board of Health
Qa`w pa`" Commonwealth of Massachusetts Map-Block-Lot
106.C-0104-
_ = 9 Board of Health -----------------------
t North Andover
Certificate of Compliance
�ACiaU
THIS IS TO CERTIFY That the Individual Sewage Disposal System (Construct)
by Todd Bateson
-- ----- ----
Installer
at No 224 RALEIGH TAVERN LANE
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2008-022 Dated December 09 2008
-- - - ---------
------- -- ----
Printed On:Dec-09-2008
- ------------------------------------------------------------------------ Board of Health
o "ORT., Application for Septic Disposal System
-
3:•`'' '-"' ' °c
` p Construction Permit - TOWN OF TODAY'S DATE
' F' ORTH ANDOVER, AlA 01845 $250.00—Full Repair
$125.00 -Component
�Sa^cNug�
Important:. >-Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
key.
IAV Address or Lot#
City/Town r RECEIVED
2.-*TYPE OF S PTIC SYSTEM*:
❑ Pump ravity(choose one) NOV 13 2008
***If pump system,attach copy of electrical permit to application***
❑ Conventional System(pipe and stone system) TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
35--eu-t y 1-yA-- C-
L`
Name ,
Address(if different from above)
�j I�'lri � fit'8-YS
Cityrrown State Zip Code
Telephone Number
I
3. Installer Information 11
�oB� �'aT'e.$ae✓
Name /!/ f <`1(14 Name o ON ENTERPROSES9 rNC.
6I Argilla Read
Address A-4 1114 -01r10 Andover, MA 01010
Cityrrown State Zip Code — I
775?' 3
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
Citylrown State Zip Code
I
Telephone Number(Best#to Reach)
Application.for Disposal System Construction Permit•Page 1 of 2
°RTS Application for Septic Disposal Svstem
- Construction Permit - TOWN OF TODAY'S DATE
•F' ORTH ANDOVER, MA 01845 $ 250.00-Full Repair
$125.00-Component
S^c►ws
PAGE 2OF2
A. Facility.Information continued....
5. Type of Building: �esidenl Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued y this Board of Health.
P7 e
Name Date
A li
pp cat Approved By: oard of Health Representative)
Z:J
Date
A`plication Disapproved for the following reasons:
For Office Use Only: /
L Fee Attached. Yes_/ No
2. Project Manager Obligation Form Attached.P Yes No
3. Pump System? Ifso,Attach copy ofElectrical Permit Yes/1, No
4. Foundation As-Built. (new construction ronly): �'Ls. No
(Same scale as approved plan)
5. Floor Pians?(new construction only): Yes o
Application for Disposal System Construction Permit•Page 2 of 2
t
it
a
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(Address of septic system) For plans by
!!>' J (Engineer)
!
Relative to the application of r"" 7.e SdN
(Installer's name) And dated
ngma date)
Dated 1 / ?-tee
o ay s ate With revisions dated
Tl' (Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager,or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection.without completion of the items in accordance
with Tide 5 and the'Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally,this is the first (1'� inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc.
As-built of verbal OK (or e-mail to: healthd t&townofnorthandover.com) from the engineer must.
be submitted to the Board of Health, after which installer calls,for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade-Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank,D-Box,pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer,I understand that I am solely responsible for the installation of the system as per the
a1212roved plans No instructions by the homeowner,general contractor or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date) //- 7—'
arae—Print) =Signed)
NORTH
�a
`O
ryy
T a y
T
Co' T
O cocwiwiww.w 1•
AOR1.r
SSAC HUSH
PUBLIC HEALTH DEPARTMENT
Community Development Division
CE 1��II FI�.A2'E O F CO�V1�1'GIA��E
As of:
Apli(101 2009
This is to cert that the individua(subsurface disposal system received a
SA0~IS,FACT'ORT 1XS(ECTIOX of the:
replacement of the
T4stridution Boal
By:
ToddBateson
At:
224 X kl yh 2avem .Gane
911ap — 106.C; Tarcel- 104
North Andover, W,4 01845
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
an T Sa �—
North Andover Board of Assessors Public Access Page 1 of 1
r
"ORT" North Andover Board of Assessors
L41SSS"`""gee roperty Record Card
Click Seal To Return Parcel ID :210/106.C-0104-0000.0 FY:2008 Community:North Andover
SKETCH PHOTO
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Summary
Residence
Detached Structure '
-
Condo
224 RALEIGH TAVERN LANE
Commercial
Location: 224 RALEIGH TAVERN LANE
Owner Name: LYNCH,JERRY
GERALDINE LYNCH
Owner Address: 224 RALEIGH TAVERN LANE
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 7-7 Land Area: 1.29 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2608 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 584,700 609,600
Building Value: 357,700 370,700
Land Value: 227,000 238,900
Market Land Value: 227,000
Chapter Land Value:
LATEST SALE
Sale Price: 149,500 Sale Date: 11/17/1982
Arms Length Sale Code: Y-YES-VALID Grantor: FARR GEORGE H
Cert Doc: Book: 01620 Page: 0344
http://csc-ma.us/PROPAPP/display.do?linkId=1181604&town=NandoverPubAcc 12/9/2008
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i
COMMOi�.�ALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 224 Raleigh Tavern Lane_
_North Andover_
Owner's Name:_Jerry Lynch RECEIVED
Owner's Address:_224 Raleigh Tavern Lane
_North Andover,MA 01845_
Date of Inspection:_9/25/2008°
OCT —19 2008
Name of Inspector:_Neil J.Bateson_ TOWN OF NORTH ANDOVER
Company Name:_Bateson'Enterprises Inc._ LHEALTH DEPARTMENT
Mailing Address:_111 Argilla Road_
_Andover,MA 01810_
Telephone Number:_(978).475-4786
CERTIFICATION STATEMENT t 4
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
X Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: UJDate: 9/25/2008_
IV U
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.
Title 5 Inspection Form 6/15/2000 page 1 /j
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_224 Raleigh Tavern Lane_
_North Andover—
Owner:_Lynch_
Date of Inspection:_9/25/2008_
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any
information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304
exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
X 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.D-Box needs to be replaced.
N 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:
N 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:
N 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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_224 Raleigh Tavern Lane_
_ North Andover_
Owner:_Lynch_
Date of Inspection:_9/25/2008_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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.
PP Y �'Y
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for 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: f
Title 5 Inspection Form 6/15/2000 3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_224 Raleigh Tavern Lane-
-
North Andover—
Owner:_Lynch_
Date of Inspection:_9/25/2008_
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
_No_Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
No_Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
— _No_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No_Liquid depth in cesspool is less than 6"below invert or available volume is'/2 day flow.
_No_Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_No_Any portion of the SAS,cesspool or privy is below high ground water elevation.
_No_Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No_Any portion of a cesspool or privy is within a Zone 1 of a public well.
No_Any portion of a cesspool or privy is within 50 feet of a private water supply well.
No_Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No_(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 system the system must serve a facility with a design flow of 10,000 gpd to 15,000
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 II of a public water supply well
i
! 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_224 Raleigh Tavern Lane_
_North Andover_
Owner:_Lynch_
Date of Inspection:_9/25/2008_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes_ Pumping information was provided by the owner,occupant,or Board of Health
_No_Were any of the system components pumped out in the previous two weeks?
_Yes_ Has the system received normal flows in the previous two week period?
No_Have large volumes of water been introduced to the system recently or as part of this inspection?
_Yes_ _Were as built plans of the system obtained and examined?
Yes_ _Was the facility or dwelling inspected for signs of sewage back up?
_Yes_ _Was the site inspected for signs of break out?
Yes Were all system components,excluding the SAS,located on site?
_Yes_ _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?
_Yes_ `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:
Yes No
_Yes_ _Existing information.
_Yes_ _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))
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_224 Raleigh Tavern Lane-
-North Andover—
Owner:_Lynch_
Date of Inspection:_9/19/2008_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_Number of bedrooms(actual):_4_
DESIGN flow based on 310 CMR 15.203_600_
Number of current residents:_2
Does residence have a garbage grinder(yes or no):_No_
Is laundry on a separate sewage system(yes or no):_No_
Laundry system inspected(yes or no):
Seasonal use:(yes or no):_No_
Water meter reading:_Yes_
Sump pump(yes or no):_No_
Last date of occupancy:_Current_
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):`gpd
Basis of design flow(seats/persons/sgft,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:_Pumped last year,owner_
Was system pumped as part of the inspection(yes or no): Yes_
If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_
Reason for pumping: _Inspect tank&tees
TYPE OF SYSTEM
_X_Septic tank,distribution box,soil absorption system
Single cesspool_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information_26 years old,
8/30/1982,As built plan_
Were sewage odors detected when arriving at the site(yes or no):_No
Title 5 Inspection Form 6/15/2000
6
Page 7of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_224 Raleigh Tavern Lane
_North Andover_
Owner:_Lynch_
Date of Inspection:_9/25/2008
BUILDING SEWER_X_ (locate on site plan)
Depth below grade:_24"_
Materials of construction: __cast iron _40 PVC_other
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.) _ Unable to see piping,finished cellar _
SEPTIC TANK: X
Depth below grade:_12"_
Material of construction: X concrete,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:_10'x 5'x 4'
Sludge depth:_6"_
Distance from top of sludge to bottom of outlet tee or baffle: 21"_
Scum thickness:_6"
Distance from top of scum to top of outlet tee or baffle:-
8"-Distance from bottom of scum to bottom of outlet tee or baffle: 15"_
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._Pumped septic tank.Inlet tee ok.Outlet tee ok.Depth of
liquid at outlet invert Outlet cover under cement walk
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_224 Raleigh Tavern Lane
_North Andover—
Owner:_Lynch_
Date of Inspection:_9/25/2008_
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.):
DISTRIBUTION BOX X
Depth below grade _18"_
Depth of liquid level above outlet invert:_0_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.) __P-box level&distribution equal.Evidence of leakage.Evidence of carryover.
PUMP CHAMBER:_(locate on site plan)
Pump in working order(yes or no):_
Alarm in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 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:_224 Raleigh Tavern Lane
_North Andover_
Owner:_Lynch_
Date of Inspection:_9/25/2008_
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_Leaching pits,number: _
Leaching chambers,number:
Leaching galleries,number:
_Leaching trench,number,length:
X Leaching field,number,dimensions: _1 field 27'x 46'_
Overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):_Soil ok.Vegetation ok.No sign of ponding to surface_
CESSPOOLS:
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of sludge 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 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.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_224 Raleigh Tavern Lane
_North Andover_
Owner:_Lynch_
Date of Inspection:_9/25/2008_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building
Driveway
House Wate Mater
Rear Door
B A
Porch
Septic Tank
A to Inlet=25'3"
Pool A to Outlet=33'9"
B to Inlet=2313"
D-Box B to Outlet=1.6'11"
B to D-Box=27'
C to D-Box=33'
Title 5 Inspection Form 6/15/2000 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:_224 Raleigh Tavern lane_
_North Andover_
Owner:_Lynch_
Date of Inspection:_9/25/2008_
SITE EXAM
Slope_No_
Surface water_No_
Check cellar _Yes_
Shallow wells No
Estimated depth to ground water_4`_
Please indicate(check)all methods used to determine the high ground water elevation:
_X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/24/1980_
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: As per design plan_
Title 5 Inspection Form 6/15/2000 11
Summary Record Card generated on 919Q008 2:03:56 PM by Lisa Evans Page I
Town of North Andover
Tax Map # 210-106.C-0104-0000,0
Parcel Id 17738
224 RALEIGH TAVERN LANE
LYNCH, JERRY
224 RALEIGH TAVERN LANE
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.29 Acres
FY 2009
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
LYNCH,JERRY Payor
224 RALEIGH TAVERN LANE
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Activelinactive
Bldg Id.14151.0-224 RALEIGH TAVERN LANE Last Billing Date 9/3/2008
2100135 02 Cycle 02 Active
UB Services Maint.
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 117.06 /1
UB Meter Maintenance
Serial No Status Location Brand Type Size YTD Cons
0027912910 a Active ENC F.L. METE METE w Water 0.63 0.63 30
Date Reading Code Consumption Posted Date Variance
8/1/2008 4809 m Manual estimate 30 9/12/2008 13%
MSG
5/1/2008 4779 a Actual 25 6/18/2008 24%
2/4/2008 4754 a Actual 22 3/14/2008 -43%
11/1/2007 4732 a Actual 37 1/15/2008 -34%
8/2/2007 4695 a Actual 56 9/14/2007 -100%
5/3/2007 4639 c Correction 0 6/26/2007 -100%
SEE NOTE
2/28/2007 4639 m Manual estimate 21 3/23/2007 -72%
11/2/2006 4618 m Manual estimate 60 12/22/2006 109%
MSG
8/1/2006 4558 a Actual 21 9/13/2006 50%
5/25/2006 4537 a Actual 23 6/20/2006 -6%
2/2/2006 4514 a Actual 20 3/13/2006 -33%
11/2/2005 4494 aActual 27 12/14/2005 -57%
8/11/2005 4467 a Actual 69 9/12/2005 303%
Trouble Code:09
5/11/2005 4398 m Manual estimate 16 6/8/2005 1%
2/14/2005 4382 a Actual 16 3/15/2005 -3%
Trouble Code:09
11/19/2004 4366 a Actual 19 12/17/2004 -44%
8/11/2004 4347 a Actual 29 9/20/2004 38%
5/17/2004 4318 a Actual 22 6/14/2004 26%
2/17/200.4 4296 a Actual 20 4/16/2004 0%
11/6/2003 4276 n New Meter 0 11/6/2003 0%
Tel: (978)475-4786
Fax: (978)475-5451
BATESON ENTERPRISES, INC.
Excavating-Water& Sewer Lines-Septic Systems&Pumping Service
111 Argilla Road Andover,Mass. 01810
Title 5 Inspection Report
Property Address: 224 Raleigh Tavern Lane,North Andover
Owner: Lynch
Date of Inspection: 9/25/2008
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
PJBates)on&��
Bateson Enterprises,Inc.
i
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
I
A. Facility Information
Whenrfilling out 1. System Location: Left front, left rear, left side of house. Right fron , right rear 'ght sid of house.
forms on the
computer,use
only the tab key Address ! ,^ ^
to move your1�`���1 L
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner
Name
caws.....:........ .. Address(d Merent from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:d:
Gallons
3. Type of system: Cj Cesspool(s) E5-Septic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes EI ivo If yes,was it cleaned? p Yes [ No
5. Condition of System:
YID c�' A �`� •�
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle Lioense Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
igna ure of H"r Date
t5form4.doc•06/03 System Pumping Recons•Page 1 of 1
I
Commonwealth of Massachusetts ;� �p
City/Town of
System Pumping Record OCT 15 2007
Form 4
TONIN OF NORTH ANDOVER
HEALTH DEPARTi\1ENT
DEP has provided this form for use by local Boards of Health-OtheP foims may be used, but e
information must be substantially the same as that provided here. Before using this form, ch with your
local Board of Health to determine the form they use. The System Pumping Record must be su itt to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not State Zip Code
use the return
C
�Y
key. 2. System Owner:
Name
1�3C�1 Address(if different from location)
City/To Nn7Zip
Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes,was it cleaned? ❑ Yes ❑ No
5. ConditionoSystem: �
r \ � i,
� vi�- 4z::�u�
6. Systemu ped By:
..� �
Name Vehicle License Number
Company
7. Location a rpontenU were osed:
signaturg(ofAultr Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I RECEIVED
System Pumping Record
Form 4 OCT 12 2006
TO^� O� ,OeTH ANDOVF_R
DEP has provided this form for use by local Boards of Heal h. The System;Pumping Record must
be submitted to the aocal Board of Health or other approving au�hortt�
A. Facility Information
Important:
When filling out 1. System Location:
fomes the
computer.use �..J
only the tab key Address
to move your
cursor-do not
use the return CitylTown `tel State
Zip Code
key. 2.. System Owner:
eA, -
Name
Address(if different from location)
City(rown Stat ^ ip Code
Clef
Telephone Number
B. Pumping Record
1_ ate.of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(S) eptic Tank ❑ Tight Tank
❑ Other(describe).`
4. Effluent Tee Filter present? ❑ Yes ❑ o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: .
0� U
6. System Pumped By'
Name Vehicle License Number
Company .
7. Locatio here contents were osed::
Signa e f u er Date
http://www.mass.goylde /w er/approvals/t5forms.htmAnspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF U
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house) .
�vobsse
DATE OF PUMPING. QUANTITY PUMPED : GALLONS
CESSPOOL: NO 1/ YIr:S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
I
Commonwealth of assachusetts
Ljno , Massachusetts RECEIVED
OCT 19 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
System u ping Record
System Owner System Location
Y Ack Y
Date of Pumping: (,0— Quantity Pumped: 506 gallons
Cesspool: No [ Yes [] Septic Tank: No [] Yes
System Pumped by: 64&44ot License#
Contents transferred to: Greater Lawrence Sanitary District
Date: I Q Inspector:
TOWN
OF P �
SYSTEM PUMPING RECORD
Vic¢°OF�
DATE: a `
SEP`15%
SYSTEN7R& ADDRESS SYSTEM LOCATION ,, ---
(example: left-fr nt of house)
LA,' -
2
DATE OF PUMPING: QUANTITY PUMPED : b GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: it-i,3-o )
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
A (example: left front of house)
T0� kcus-c
fT
�J (Al.
DATE OF PUMPING: 1Ti -o I QUANTITY PUMPED �S cc— GALLONS
JCESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
�r 'i OF ,
OBSERVATIONS: NOV 3 0 2801 {
GOOD CONDITION FULL TO C
HEA COVE
VY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD,RUNBACK !
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY. A �✓��
COMMENTS:
CONTENTS TRANSFERRED TO: 1, l
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
Date of Pumping: Quantity Pumped: b�0Wllons
Cesspool: No f r' Yes [] Septic Tank: No [] Yes [�
System Pumped by: 04&4" License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
fc -.
27
)('onnnonwUalassachusetts
Massachusetts
System Pumping Record
System Owner System Location
late of Pumping: Quantity Pumped: gallons
Cesspool: No,w-- Yes H Septic Tank: No �._� Yes --
System Pumped by: Felre4ort Sil&e"t tiw License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
EV )F NORTH AMID(
PC,"-RD OF HEALF4
H.
r 2 2 igJJ
North AnPver,Haas. BEPTIC SISTEK
INSfALLATICK CH3CCK LIST LOT �G.,e, M i
J
w
C1VED DAT PROVID AVATIC�1 OK FAIL
_ easnnst /d E
1
s.� FAIL M
1. Distance Tot
a. wetlands K ` C-1130PvvL lvGO
/ b. Drains
/ Z c• Well
2. Water Line Location
l�
Septic Tank
a. -Tees -_Length & To Clean Out Covers. .
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts _-
C. No Back Floss
6. - Leach Field or Trench
a. Dimensions
i b. Stone Depth
c. Capped Eads
d. Clean Double-Washed Stone' �.
7. Leach Pits
' a. Dimens s
b. Ston Depth
c. ash Pads
d. eas
e Cement Pipe to Pit - Both Sides. -
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted-
a. Lot Location . - ------ -.
b. Dimensions of System
c. Location with Regard-to Pere Test _
d. Elevations
` e: Water Table
L
Board of Health
North Andover,Mass .
SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT
APPROVED DATE Y-!-r�d�- DISAPPROVED DATE
Provided: Reasons:
�c66
Title V FAIL 09
Reg 2.5 The submitted plan must show as a m3nimmm=
Fes` ✓ a) the lot to be served-area,dimensions loti ,a tters
b location and log deep observation hoes-dis I'e to ties
location and results percolation tests-dis a to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system-including reserve area
f) existing and proposed contours
t/ (g) location any wet areas within 100' of sewage disposal system or
disclaimer-check wetlands mapping
IN surface and subsurface drains within 100' of sewage disposal
system or disclaimer
N A,J(i) location any drainage easements within 1001 of sesage disposal
system or disclaimer-Planning Board files
AAA 10). known sources of mater supply within 2001 of sewage disposal
system or disclaimer
/V. (k) location of any proposed well to serve lot-1001 from leaching facility
(1) location of water lines on property-101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximam ground water elevation in area sewage disposal system
✓ (s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
;11(a) capac t es- 50; of flow, mater table, tees, -depth of tees,
access, pumping
:✓ (b) cleanout
(c) 101 from cellar wall or inground swimming pool
IV.A • (d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
a) ope greater than 0.08
Reg 10.4L=±:db) sump
� Board of Health
North tndover,Mass
SUBSURFACE DISPOSAL DESIGN CHECK LISP
LOT J I
APPRMW DATE .SC, DISAPPR07M DATE-
Prq ded. f Reasons:
,� r_65
� �,.:d'�.��f�s�✓'pia ,D,�(� -
Title V FAIL
Reg 2.5 The submitted plan must show as a minim=-.a) the lot to be served-area,dimensions lot #,abutters
€. b location and log deep observation hoes-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
PKI (e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any wet areas within 1001 of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any drainage easements vithin 1001 of sewage disposal
system or disclaimdr-Planning Board files
(3) known sources of water supply within 2001 of sewage disposal
system or disclaimer
k) location of any proposed well to serve lot-1001 from leaching facility
(1) location of water lines on propsrty-101 from leaching facility
^�(m) location of benchmark
(n) driveways
+✓(o garbage disposals
X,4 (p no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution boa inlets and outlets, distribution field piping and
Mer elevations
✓ r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Sg2tic Tanks
(a) capac t es- 5056 of flow, water table, tees, depth of tees,
access, pumping
b) cleanout
(c) 101 from cellar wall or inground swimming pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope greater 0.08
Reg 10.3 b) sump
t
Commonwealth of Massachusetts
RI�/ �
City/Town of NOV 2012 �
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4 L HEALTH DEPARTMENT
M
DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house,(�WRigh ear of=home, /right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
9 It
Name (,j j
Address(if different from location)
City/Town State Zip Code
® S 5 0 o
TelephoneNiumber
B. Pumping Record
1. Date of Pumping 11r Li— 2.
Date antity Pumped: Gallons-
3.
allons 3. Type of system: F-1Cesspool(s)
Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name .Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatiQnwhere contents were disposed:
G.L S. Lowell Waste Water
-L r_ I - f
Signitufe qf Haule Date
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