Loading...
HomeMy WebLinkAboutMiscellaneous - 24 GILMAN LANE 4/30/2018 (2)I N C O ? V � D �?; Z � Z o R' 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 19 2001 TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address• Date of Inspection:. i Name of Inspector: (please print)k a 'an, 911 Company Name:1)"ra Mailing Address: Wj— Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority A Fails _ A Inspector's Signature: Z 1A41cY6 Date: The system inspector shall sub t a copy of th' inspection r ort to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspec ion. 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 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:. Owner: Date of Inspecti6j: ID 0� t Inspection S mary: Check A,B,C,D or E / ALWAYS complete all of Section D A. Syst Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced o;. repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. - The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipes) are replaced Obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner• Date of Inspecti : ` 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. 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 morefrom 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. I Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:n94 (IV Owner: nA 31 Date of I,SpectiD. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes N 7 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool . Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number Of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surfaca water supply. �Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: v� 1 To be considered a large!system the system must serve a facility with a design flow of 10 gpd, l; ,000 gpd to 15,000 You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. `Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST bfii $ . II . 1 .1' A is � � � �� � �► Check if the following have been done You must indicate "yes" or "no" as to each of the following Yes o — Pumping information was provided by the owner, occupant, or Board of Health _ ,,,Were any of the system components pumped out in the previous two weeks ? ✓ Has the system received normal flows in the previous two week period ? YHave large volumes of water been introduced to the system recently ecently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out ? Were all system components, excludingthe SAS located ated on site ? Were the septic tank manholes uncovered opened, of the affles or tees, material of construction, dimensions, depth of 1 quid, depth of sludge e interior of the nd depth inspected oof the condition _ 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: Ye no _ Existing information. For example, a plan at the Board of Health. ' Determined in the field (if any of the failure criteria related to Part C. is at issue approximation �s unacceptable) [3 10 CMR 15.302(3)(b)] of distance 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: . Owner. IiLsi� 1&0 Date of Inspecti : FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of be (actual): y DESIGN flow based on 310T 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage _ 4 t� g g grinder (yes or no): i,� Is laundry on a separate sewage system (yes or no): O'if yes separate inspection required] Laundry system inspected es or no): _ Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)) Sump pump (yes or no): MtLO Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): ____gpd Basis of design flow (seats/persons/sgketc.): 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: _ Was system pumped asrajttthia nspection ��or no): If yes, volume pumped: allons — How was quanti pumped determined? Reason for pumping: n % A L f.. , _A h. TYPE OF SYSTEM w 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 T Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): _ Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert4Address:,. Owner:Date of BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other (explain): Distance from private water supply well or suction line: ft Comments (on condition of joints, venting, evidence of leaks e, etc.): SEPTIC TANK: N (locate on site plan) Depth below grade: e' Material of construction: ✓concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): certificate) _ (attach a copy of Dimensions: CO-, ti Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: �Or� Scum thickness: III Distance from top of scum to top of outlet tee or baffle:�� Distance from bottom of scum to bottom of outlet tee or baffle: y �� How were dimensions determined: Comments (on pumping recommendatiobs, inlet and outlet tee ora condition, structural integrity, liquid levels as relatek to outlet invert, evidence of leakage, etc.): /� n / �MM1.0 via UJr�ary m\A ' A -AA Vl It A O�► . 41 D v,,A 0 n 0 n! / (it, GREASE TRAP:VOlocate 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.): 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 - Owner: Date of Inspect n• _ 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 (if present must be opened)(locate on site plan) 14 Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage intopr out of box, etc.)_ PUMP CHAMBER: ovate on site plan) Pumps in working order s or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 . OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) jjj =1 �1 Au .. �..i_ ..l ..�� �MEW � 1at of i i / SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: 1 ching trenches, number, length: ching fields, number, dimensions: _90' Y4o overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, etc.): damp soil, condition of vegetation, IV CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspec ' n: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 0901 r� y r' a 5-6 �o, 3 Tk, -page 11 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address- _ Owner: Date. of spe n: _io� SITE EXAM Slope surface water VCheck cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: 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: must describe how you establ� bqJ th high ground 1) 11 I mN©LAM J aM0'M�OOrr a H r07�OMMT© O MNNCCLAC ZZ0 NNNr� }:{{C i ui C }ZJF�Ta0MOD.0 �z } O W C T r r T r N N N N N N N N ! $CNS T C -T 04MMOD €N r�OTM�00D0� © S a= r T r r r © O N N N N N N N fl: N OC a ��o- I aavvwvr 1 0.avanvv <O 1 W 0.0.=vvvv 1 Q rrNNNNN i O NODOD00a.0 iI y 0 00N W L\A0 N Z I vTanvry _! I NNNNNNN . OD I W II I 1 I I I o T r r eW1} vvvv=vv j I- I GD NNNNNNN I *C rNM0M+0N 'r W coca=== Q N W ===coca L6 v v=vvTTr �= O N - j•• Conoco= 3. � o=vvaav CC LAJ ui O „irk NaLA " S 0004M -00.T W . . . � roo�oM�va 6A�,4 ! ti .0 M 0 ar 7 _ mc:T r ZZ0 NNNr� }:{{C i ui C }ZJF�Ta0MOD.0 �z } O W C T r r T r N N N N N N N N ! $CNS T C -T 04MMOD €N r�OTM�00D0� © S a= r T r r r © O N N N N N N N fl: N OC a ��o- I aavvwvr 1 0.avanvv <O 1 W 0.0.=vvvv 1 Q rrNNNNN i O NODOD00a.0 iI y 0 00N W L\A0 N Z I vTanvry _! I NNNNNNN . OD I W II I 1 I I I o T r r eW1} vvvv=vv j I- I GD NNNNNNN I *C rNM0M+0N NEW LOT LINE 271. 48' ORIGINAL LOT LINE _. ABSORP' LOT 23-A 46, 008 S.F. . 32 3 5 .INVERT ELEVATIONS AT HOUSE .............. . TANK INLET.......... 186.42 TANK OUTLET .. . DIST. BOX INLET... 186.30 DIST. BOX OUTLET 186.11 END OF LINES.. . . ..-186.02 ..185.83 Commonwealth of Massachusetts Cityrfown of System Pumpling Record NORTH ANDOVER Form Q DEp has provided this form for use by local Boards of Health. Other forms may be used, but the informaflon 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 HeaEth or other approving authority within 14 days from the pumping date in accxdance with 310 CMR 15.351. A. Facility Information Important" When fling out 1. System Location: f roans on the use j I' l.YA�'+ 1 ti 6 n computer, use--��--- -,— ........ _....._._ .... ...._.....v---� _.... _... ,....... _ .. ..... _. Only the tab my Address /J to move your cursor - do not �— •� • . • _.._ _ r ..—....., .... ...... _. .. _ _ .. use the retum Cltyrrown State Zip Code key- 2. System Owne Name.._. _. ,..._. .... ....,� .. Address (if different from Location) Citylrown '------ - - ..�, --• --• ^—' state ...�.. ...... ....,..�,_._ Zip ��,�--...... _ Telephone Nu►nher r._. B. Pumping Record 1. Date of Pumping^! •.w_� 2. Quantity Pumped: Da#e Gallon's s 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight TaM< © Grease Trap ❑ Other (describe): .. _. — '.. —_ . , .... ..._, . _ .._....... -._ ...... . . 4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: r- -It�..,._......... ,...__..�.._._. --o f�......_ . Name Vehl a uconse Number l Com y 7. Location where contents were disposed: __.._�_...__�.�_ Worth. A>l ver,,, --MA.. , Signature of t Uler Date Signature of Receiving Facility Date t5lamwdoc• 03106 System Pump ft Reetud . Page t of t - SOIL PROFILE & PERCOLATION TEST DATA. S Start Saturation a3-a� 4� 1►ort;i And�ver,l,�ss. No.&Street �-l� Lot No. Loc./Subdiv. i Plan Owner Investigator - .Observer Dr_p of 3" -Time - o� � Dro of 6" -Time SOIL PROFILES. -DATE 1. Elev. I•;ins _ 1st - 3"Drop 15" �• Elev,.. --- 3. Elev. 4.Elev. 0 0 -. 0 .. - — 0 - Percolation Rate— Ties to Test Pits 2 2 2 2 3 - 3 3 3 _ 4 4 4 4 S S 5 $ .6 6 6 6 7 ., , 7 7 7 8' 1W 9 10 l 1 10 1 10 Benchmark 'Location Elevation Datum lPercolation Tess -Date 8 9 10 yavv----- Pit Number S Start Saturation Soak -Mins_ - Start- Test -Time ___- _-- -__-- ---- Dr_p of 3" -Time - Dro of 6" -Time I•;ins _ 1st - 3"Drop 15" 3 Mins. 2nd 3"Dro / - Percolation Rate— SOIL PROFILE & PERCOLhTION TEST DATA. North Andover,lass. No.&Street% ��Lot No. -- Loc./Subdiv. Plan Owner Invest i.gator - Observer.- SOIL PROFILES -D TE Elev. — Elev. A.- Elev. . _.^E1 v . 0 0 �- _ 0 -. 0 27fS 2 - 2 2 Ties to Test Pits _ 3 - 3 3 3 - - Benchmark Elevation 9 7 Location Datum Percolation Tess -Date - t Pit Number- - - _ - 1 . 3 4 S Start Saturation Soak-P'Jins _ ----=------ - - - _ --- -- - •- - - - - • - - -- -- - =---_- Start- Test -Time __- Dr_p of 3" -Time = r Drop of G" -Time I•Sins.Ist. 311Dr0. Mins . 2nd 3"Dro _ Percolation Rate F�pni�2�System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumping Record Sym Owner system Location -1100— Type: Emergency Cesspool: No Date of Pumping: / System Pumped By: Contents transferred to: Contents Disposed at: Routine (/ Yes Septic tank: NoPye. Z 'r3 I Quantity Pumped: CGallons Wind Neer Environmental, LLC Permit 7t: Date: Pumper Signature: Condition of System/Other Comments Dep Approved Form - 12/07/95 :" 00 OD OD OD aD W N — O N J f J� O _N w ov,�za� X ry '� _ 000c0zc C a. OD X� x x .,.{ r rr rmmr , m zcrm -4 �. (� MN -4 ;U O W 2� ADS f` D Jr - 0 -� z 0. 0 < cn n � z :" 00 OD OD OD aD W N — O N I J f J� O _N w rn C a. OD X� z N,-V rn -4 N (� MN -4 ;U O W 2� ADS f` D Jr - � v 'O `Wt z 0. 0 < cn n � m m,m �z O I 6I�,\ 3Nd 1 w !a m z ln r r 0 r O r � Z m r z m Im I O rn C z N,-V rn -4 N (� MN -4 ;U O W 2� ADS f` D < v � y z 0. 0 < cn n � m m,m �z O ;0 3 m m D Z 3 � n 3 c (� >r !n N > z -4 N m m cn 00 �y 6I�,\ 3Nd 1 w !a m z ln r r 0 r O r � Z m r z m Im I Board y` R4 alVii North F= U FA SEMO S73TEM INSTALLATION CF'rK Ll ST 1 gya iD 0W LOT` 1. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PPC Pipe fit. 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 Flow b. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pi a. one b. th r:K� c.h Pds d. e. Cent Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final trading Inspection Oe 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 Iver nsuttants inc. 213 BROADWAY METHUEN, MASSACHUSETTS 01844 (617) 687-3828 DATE U - 02- M TO : NORTH ANDOVER HEALTH DEPARTMENT TOWN HALL , NO. ANDOVER , MASS RE : SUBSURFACE SEWAGE DISPOSAL SYSTEM 4 o7" 03 •./4 f �'�rn.t�7 ���e NO. ANDOVER , MASS. I hereby certify that I have inspected the construction of the disposal system at Col` Z3- A ­,,'/r��" GahG North Andover, Mass. and that the location and elevations are as shown on the As -Built Drawing dated Qewl- Z2, /,M/ . ANDOVER QONSULTANTS , INC. William S. MacL od Registered Sani arian This certification is notto be construed as a guarantee of the system. rnvv-f—tD Z q - P _N W U) U) rn O r O Doo 2 00 cZU) ;� t z xx.-�r D 1- O Z rn _ Zci--+ M -4 m-�ri U) w 1� J DDS D D z 0 O 1 (� y z v- <co d m Or. n O m ao 0o OD ao CA cn OD 0 = W .A W N O N 9 rn . q - P _N W 0 rn O r O Doo N CD 0 ;� t z D W N W -Q o q - P _N W CD zr (n< CSD _ M -4 in U) w 1� J DDS D D z 0 O 1 (� y z v- <co d m Or. n O m ��z rn s m D fl Z U A U) D Cn -. N (\ cn z rn rn n ao o O zr 00 M -4 w 2N DDS D D z 0 O 1 (� y z v- <co d m Or. n O m ��z rn m D fl Z U A U) D Cn -. N (\ cn z rn rn ao "I D OD U) O M .i I 10z M m D lr, 1c) r r 0 r- 4 z m r i m 3Nd .O O� I oCV O ' r Board of FeA.!►*th North A,n kik ar," 's WBSUPFACE DISPOSAL DFSIGN CHWK LIST LOT` -- -- - 4 APPROvjM DATE_ DIWPROM DATE_____, Provided** Reasons AW Ti 9 FAIL ['vg�s., Reg 2.5 CIA - The submitted plan must show a a minimum*- a) the lot to be served-area,dimensions lot #,abuttera b location and log deep observation hoes -distance to ties c location and results percolation tests -distance ieeaching� design calculations & calculations showing required (e) location and dimensions of system -including neserve area f) existing and proposed contours g) location any wet areas within 100' of sewage disposal system or disclaimer -check watlends rapping h) surface and subsurface drains v;�lthin 100' of sewage disposal system or disclaimer L (i) location any drainage a-.r_e=,its I.? thin 100' of s6 ,_-ge disposal system or disclaimer- Pl .. ing Board files ("j) lo2o�n sources of anter sWply within 200' of mage disposal system or disclaimer (k) location of proposed well to serve lot -100' from leaching facility (1) location of water lines on property -70' from leaching facility location of benchmark tr) driveways (o) garbage disposals (p) no PVC to be used in construction septic tank (q) profile of system -elevations of basement, plumb, Pipe., , distribution box inlets and outlets, distribution field piping and Other elevations . e (r) maximam ground water elevation in area sewage disposal system o (s) plan must be prepared by a Professiouml. Ragineer or other professional authorized by lax to prepare such plans Reg 6 Septic Tanks (a) capac t os -750% of flog, water table, tees, depth of tees, access, pumping b cleanout (c) 10' from cellar v-anor inground sudmud.ng pool (d) 25' from subsurface drains Reg 10.2 Distribution Boxes Ka) sIoge greater than 0.08 Reg 10.1 b) sum 1 a,a h Check List FAIL I OK 6 1 F Leaching Pits Leaching pits we preferr--d i re the ;nstallation is possible Reg 11.2 11.4 11.10 11.11 Reg 15.1 15.4c 15.8 3.7 a)calculations of lbea ng area-ui,nirim 570 eq ft b) spacing c •surfac�-drainage 2% d covWmaterial e) Pi2 I aril" splash pad f) tae at elbow g) no bonds in pipe .from d -box to pipe Leaching Fields ) no greater UM 20 minutes/inch area -rd nim= 900 eq ft construction of field ) surface drainage 2 % e) 201 from cellar wall or inground eAra d.ng pool - Leaching Trenches Reg 14.1 .3 14 14.6 14.7 1.4.10 a) calculations W leaching area -min 500 eq ft b sppacln -4,� nada 6 ft with reserve between d) construction e) stone f) sarrface drainage 2% DoLmhill 416P e be shown) a) slope;/rx- b) y/x, (to be shown) Beg 9.1 9.6 a) FFV&l b) gtand-by power Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 4:1 .nem Commonwealthof assac usetts KL IVSD City/Town,,.. d? % JUL 31 20 System Pumping Recor � Tow N Form 4 OF NORnFrTTHa' rer. ANDOVER HEALTH DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: Address OV- Ardov�,r ICtG C)18 �5 City/Town State Zip Code 2. System Owner. G�vGS Name Address (if different from location) City/Town State Zip Code - Telephone Number B. Pumping Record 1. Date of Pumping - 2. Quantity Pumped: Date 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes NrNo 5.1 Condition of System: ) .1500 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: MIV'-C, \Wi)SoYl Name Vehicle License Number \r,(;nj �;v�C ��,vt ronmen�al Company 7. ' Location where contents were disposed: Signature of Hauler 'Signature of Receiving Facility t5form4.doc• 03/06' Date Date System Pumping Record • Page 1 of 1 i Commonwealth of Massachusetts City/Town of NORTH ANDOVER _- System Pumping Record Form 4 Ma, DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days fro a in accordance with 310 CMR 15.351. TRECEIVED Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. M 1 Wore I A. Facility Information I FEB - 4 2010 1 System Location: 2q 6 ,')roar. Z)-\ - Address City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT State Zip Code State Telephone Number Zip Code 1. Date of Pumping I / 2. Quantity Pumped: G/1S00 Date 3. Type of system: ❑ Cesspool(s) k�F�eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? � res ❑ No 5. Condition of 6. System Pumped By: —A41xe— 62 — Name n Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No l Vehicle License'NUmbef( N g. Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1