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HomeMy WebLinkAboutMiscellaneous - 240 ABBOTT STREET 4/30/2018 (2)m N 0 Commonwealth of Massachusetts LHEALTH ED City/Town of 2008 System Pumping Record aF Form 4 ANDOVER RTMENT 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 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key v l� 1. System Location: Address AQ) i4� Citylrown State Tip Code 2. System Owner: �� C Address (if different from location) Cityrrowm B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code r ©? Telepf one�u-Z Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of If yes, was it cleaned? ❑ Yes ❑ No 6. System Pu pfd By:, Name,^ Vehicle License Number Company Y 7. Location whew -contents were disposed: Signature of s Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 E CA Commonwealth of Massachusetts LIF �i:�. r City/Town of I APR2 5 2006 Man System Pumping Record Form 4 EPARTN�IUT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. Systepi LOC n: forms the computer, use only the tab key Address to move your l•( 'c�"'�I cursor - do not use the,return Cityrrown State key. 2. System Owner: Zip Code Name Address (if different from location) CityfTown State Zip Code Tele"%one Number .B. Plumping. Record 1. Date of Pum In�—� PumpinDate 2. Quantity' Pumped: canons 3. Type of system: cesspool(s) ptic Tank- ❑ Tight.Tank ❑ Other (describe): 4. Effluent Tee f=ilter present? ❑ Yes Leo . If yes, was it cleaned? ❑ Yes ❑ No 5. Conditioln of System; 6. Syst�mP, Tped ..�il� I BY Name Vehicle License Number Company -- . 7. LAa whereont nts ere disposed: SDate http://www.mass.gov/valsft5forms..htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD SYSTEM OWNER & ADDRE,' BS I -e (-,, (�-qb )Au�� g+, SYSTEM LOCATION (example: left front of house) 1.4 avd-- j kouslc— DATE OF PUMPING: -10-6 QUANTITY PUMPED 1S00 GALLONS CESSPOOL: NO ZYES SEP IC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: l6 c L 5 ')� U ECE OF 146 a&LWI Street . ordi . over, 1 r,,ssar. °tsetts 011845 WILLIADh J SCO -17 irgetor October 18, 1996 Ms. Judy Ruane 240 Abbott Street North Andover, MA 01845 Re: 240 Abbott Street Dear Ms. Ruane: This is to confirm that at a regularly scheduled meeting on September 26, 1996, the North Andover Board of Health granted a waiver to defer repair of the septic system at 240 Abbott Street for five (5) years since sewer is projected for that area. In the interim, the septic tank is to be pumped regularly and if there is a back up or breakout of sewage, the system must be repaired immediately according to the approved plan on file at the Board of Health. If sewer becomes available before the five (5) year period is up, the dwelling must be tied -in immediately. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S., Health Administrator SS/cjp r cc: Occupant File ; £->i ^JSE:�;\rraA„-45 v i�Gv. II.DC{'ti FA. I CD to (D O -h �n Q rt p n v 0 n a 0 c� avc oc� co r rt 1 06 fD o ED m C 3 v 3 C 0 H m 4D 2 rp c' 3 0 CL 3 I CD to (D O -h m E p ra DATE TIME AM %% 1 is : 3 l'" I'M N0. � :7 7(p S✓..._ EXT. ❑I CALL RETURNED ❑ I SEE YOU ❑ I AGAIN ALL ❑ I WAS�j✓TO WILL 1RF T ❑ r3 cd _� O O O v� 6�7- 6N9 r3 m� ° o ƒ §'.0 A 0 Q g CD m :3CD f � � \ � CL / o @ 2 0 \ 0 /z g X • 0 7 / (A 0 2 z ° & @ D ® 2 7 ƒ sw 0 7 LA ° X C) 0 ) . g m < m I r A o ¥ 3 q LA > C « 0 0 k ) q \ 3 C « w § t o 9 E ° m 3 0 # � 2 = ' P > § ) 3 7 C�l } k Z P . a � � X X. Commonwealth of Massachusetts NO 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. A. Facility. Information 1. System Location Rig n�hou ,Left /Right rear of house, Left /right side of house, LeftRight side of buil2g., Left ! Rigilding, Left / Right rear of building, Under deck Address Cityfrown C� ! xJ t_ J� state Zip Code 2. System Owner. Name' Address (d different from location) City/Town State Code Telephone Number i., B. Pumping Record 1. Date of PumpingDate2. Quantity Pumped: canons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of System: 6. System Pumped By: 7. Neil Bateson Name i Bateson Enterprises Inc Company were disposed: Dwell Waste Water F5821 Vehicle License Number Data rc),- t t5form4.d" 06103 System Pumping Record • Page 1 of 1 h Town of North Andover+ NORTM OMCE OF 3 04 "',. [ COMMUNITY DEVELOPMENT AND SERVICES 0 146 Main Street North Andover, Massachusetts 01845 ��ss,cNusti`s� (508)688-9533 October 21, 1996 Mr. William Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 240 Abbott Street Dear Bill: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1, Plans not stamped. 2. Leach area less than 100 feet to wetlands. 3. Primary leach lines less than 4 feet to reserve. 4. Less than 10 feet between trenches. 5. What are elevations of pump chamber outlet and D -box inlet? If you have any questions, please do not hesitate to call the Board of health Office at the number below. Sincerely, Sandra Starr, R.S., Health Administrator HOARD OF APPEALS 688-9541 Julie Parriao BU11DINO 68&9545 CONSERVATION 688-9530 HEALTH 688.9540 PLANNING 688.9535 D. Robert Nioetta Michael Howard 3aafin Starr i{athloen Bradley Colwell NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: 4 6 PERMIT # S ~%� DATE RECEIVED 14/i/�6 rt APPLICANT Ley ADDRESS MAP PARCEL LOT # STREET # A46 E �1-1,5L'6WPer /-0USTREET 19860 7 S3� ' `.'�rl-iE--y. . y t 1 1 PLAY DATE REV. DATE ITIONS OF APPVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: •�-�.5:, 7�J�f�/V `D0 r 1'G7 u1�7'C/�-.u/�S .f, 1,X56 7WA v /,o ' -ge-7-avE-6'Au ,eEAu6A4E5 cf. w/lAr � c � �Ev r�vn�s o � �� n�P c ���mi3gR o �To6-7 �- -D --60)( 7 GENERAL / 3 COPIESy STAMP LOCUS '� NORTH ARROW C SCALE CONTOURS ✓ PROFILE 4—' SECTIONy BENCHMARK SOIL & PERCS `' ELEVATIONS WETS. WATERSHED?/t/o DRIVEWAY � (Elev) SCH40 L--' TESTS CURRENT? SEPTIC TANK MIN 1500G 10' TO FDN DISCLAIMER WELLS & WETSy WATER LINE'--' FDN DRAIN SOIL EVAL -3. Dore&5„j6- .17 INVERT DROP GARB. GRINDERA/0 (2 comps +200) MANHOLE il� ELEV GW ## COMPS. GB D -BOX SIZE # LINES 3 INLETA- OUTLET &) ,93 = FIRST 2' LEVEL STATEMENT L/ (2" OR .17 FT) TEE REQ'D? LEACHINGD 16, MIN 440 GPD? L--' RESERVE AREA/ 4' FROM PRIMARY? -A/- 20 SLOPE 100' TO WETLANDS 100' TO WELLS--_4_'..,.TO S.H.GW (5'>2M/INS ) ��- 20' TO FND & INTRCPTR DRAINSy 400' TO SURFACE H2O SUPP`�J 4' PERM. SOIL BELOW FACILITY MIN 12" COVER L--' FILL? (15') BREAKOUT MET? TRENCHES MIN 440 gpd� SLOPE (min .005 or 6"/100') L'�SIDEWALL DIST. 3X EFF. W OR D (MIN 61 RESERVE BETWEEY TRENCHES?y IN FILL? `� MUST BE 10' MIN.z 4" PEA STONE?VEN i./ (>3' COVER; LINES >501) BOT -3 % 0 + SIDE A46 X L G ��� TOT (L x W x #) (DxLx2x#) ( (G/ft2)) Copyright 0 1995 by S -L. Starr PLAN REVIEW CHECKLIST nn ADDRESS O�� nn /�7,' ENGINEER --�3 • D GENERAL / 3 COPIESy STAMP LOCUS '� NORTH ARROW C SCALE CONTOURS ✓ PROFILE 4—' SECTIONy BENCHMARK SOIL & PERCS `' ELEVATIONS WETS. WATERSHED?/t/o DRIVEWAY � (Elev) SCH40 L--' TESTS CURRENT? SEPTIC TANK MIN 1500G 10' TO FDN DISCLAIMER WELLS & WETSy WATER LINE'--' FDN DRAIN SOIL EVAL -3. Dore&5„j6- .17 INVERT DROP GARB. GRINDERA/0 (2 comps +200) MANHOLE il� ELEV GW ## COMPS. GB D -BOX SIZE # LINES 3 INLETA- OUTLET &) ,93 = FIRST 2' LEVEL STATEMENT L/ (2" OR .17 FT) TEE REQ'D? LEACHINGD 16, MIN 440 GPD? L--' RESERVE AREA/ 4' FROM PRIMARY? -A/- 20 SLOPE 100' TO WETLANDS 100' TO WELLS--_4_'..,.TO S.H.GW (5'>2M/INS ) ��- 20' TO FND & INTRCPTR DRAINSy 400' TO SURFACE H2O SUPP`�J 4' PERM. SOIL BELOW FACILITY MIN 12" COVER L--' FILL? (15') BREAKOUT MET? TRENCHES MIN 440 gpd� SLOPE (min .005 or 6"/100') L'�SIDEWALL DIST. 3X EFF. W OR D (MIN 61 RESERVE BETWEEY TRENCHES?y IN FILL? `� MUST BE 10' MIN.z 4" PEA STONE?VEN i./ (>3' COVER; LINES >501) BOT -3 % 0 + SIDE A46 X L G ��� TOT (L x W x #) (DxLx2x#) ( (G/ft2)) Copyright 0 1995 by S -L. Starr PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS MIN 440 GPD 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? DIST LINE SLOPE .005? >31COVER-VENT SCH 40 MIN 12" COVER RATE ( X ) X = TOTAL L W LDG DOSING TANKS AND PUMPS ~ 4� G DIMENSIONS 90 �' X ' X �� •� = PUMP rAPAC_TTY rTnM L W D Vol. DISCHARGE SIZE DISCHARGE RATE 46 DISCHARGE TIME // Al. gpm MANHOLES TO GRADE ALARM SEP. CIRC. r/ GW (Min. l' below inlet) HWL 9g•15' LWLo • CHECK VALVE 1. BLEEDER HOLEt-- MANUAL, OP. SWITCH i/ ENUF STORAGE? � Copyright 0 1996 by S.L. Starr Town of North Andover, Massachusetts NORTH BOARD OF HEALTH * f.." rD > mb "ia pDRAT E D WPP/ Applicant Form No. 1 oc± - 19 q (- APPLICATION FOR SITE TESTING/INSPECTION Site Location Engineer Test/Inspection Date and Time /�'� va Fee / CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. O�S `Eo 1646NO L `* �o cocri�rcw�c� ey q 1. Town of North Andover, Massachusetts BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant NAME ADDRESS TELEPHONE Site Location_ - - Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. ZINASEF"'r'mv- CEFTINTABLETS cefuroxime sodium/GLaxo (cefuroxime axetil) 150 mg or 1.5 g q8h 125, 250, and 500 mg Balanced Empiric Therapy Please consult complete Prescribing Information on last pages. ZIN5.33 To: North Andover Board of Health Chairman and Members From: Judy and Dave Ruane 240 Abbott Street N. Andover, MA Date: September 24, 1996 r b� We would like to request a waiver to Title 5 Section to allow repair of the septic system at 240 Abbott St., N. Andover to be 5 years from this date because sewer is proposed at end of our driveway within this five year time frame. Thank you for your consideration. 310 CMR: DEPARTNIEi`;T OF ENIVIRONTvM 'TAL PROTECTION 15.304: continued 6. if size and use of the facility is relevant to the demonstration that an equal level of environmental protection has been provided, appropriate use restrictions shall be granted to ensure that such conditions are not changed. (c) An applicant for a determination pursuant to 310 CA1R 15.304(3) shall file a request for such determination not less than two years prior to the date by which the owner would otherwise be required to obtain the groundwater discharge permit pursuant to 310 CMR 15.305(2). (d) In making any determination pursuant to 310 CMR 15.304(3), the Department shad impose such conditions as it determines appropriate to ensure protection of public health and safety and the environment. At a minimum, such conditions shall include upgrade of the system to the standards described in 310 CMR 15.304(3)(b)4., and a maintenance, monitoring and reporting plan as described in 310 CMR 15.304(3)(b)5. (4) Any system serving a facility with a design flow of 10,000 gpd or greater but less than 15,000 gpd shall be upgraded upon the order of the Department or the local approving authority when a specific circumstance exists by which the system threatens public health, safety or the environment or causes or threatens to cause damage to property or creates a nuisance as, determined by the local approving authority or the Department. Where necessary to protect public health and safety and the environment, the Department or the local approving authority may require the owner to install a recirculating sand filter or equivalent alternative technology in accordance with 310 CMR 15.202 or to obtain a groundwater discharge permit in accordance with 314 CMR 5.00 and 6.00. 15.305: Deadlines for Completion of Upgrades (1) If a system is failing to protect public health and safety or the environment as set forth in 310 CMR 15.303(1) or 15.304(1), the owner or operator shall upgrade the system within two years of discovery unless: (a) a shorter period of time is set by the local approving authority or the Department based upon the existence of an imminent health hazard, or (b) the continued use of the system is permitted by the local approving authority in accordance with the provisions of an enforceable schedule for upgrade. Bases for continued use include, but are not limited to, proposals to connect to a sanitary sewer.or shared system. A fiscal commitment to the sewering plan or shared system plan, together with an approved facility plan where appropriate, proposing connection or replacement of the failing system within five years, and an enforceable commitment by the owner to perform interim measures (for example, regular pumping) shall accompany any such local approval. Such approval shall expire in five years or upon the failure of the applicant for such approval to meet interim deadlines set forth in the enforceable schedule for upgrade and the plan. The Department may by specific written approval authorize the local approving authority to allow a longer period of time, where the municipality has provided the Department a proposed implementation schedule for design and construction and has made a demonstrated financial commitment to the construction schedule. The Department may revoke any such approval if the approved schedule is not met. 11/3/95 - 310 CMR - 548.3 TOWN OF SYSTI DATE:Q� SYSTEM OWNER & ADDRESS a ✓ �.. VIPING RECORI)��-i'5a.•n' OV 1 SYSTEM LOCAT ON (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED : Q d GALLONS CESSPOOL: NO YESSEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE-7EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS; CONTENTS TRANSFERRED To: G.L.S.D � Lowell Waste TOWN OF SYSTEM DATE: L ( l SYSTEM OWNER & ADDRESS 0A6v(-(Ao r)- 40 4�0 IG ECT�RECO,R--,DR APR I.3 2�C5 TH AND.;vr TOWw CjF NOR HEALTH DEPARTME� YS EM LOCATION (example: left front of house DATE OF PUMPING: QUANTITY PUMPED: [ GALLONS CESSPOOL: NO YES SEPTIC : NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste TO DAT T17E a AM 1' 3 PM F OF ARE ODE U q NO. ( L l +� EXT. � M E •- �� O S • A 1� ® E 7 _ %'' SIGNED PHONED ❑ BALK CALLRNED WEE SUO [:]AGAIN ALL ❑ WAS IN ❑ URGENT ❑ DO TOW BOAINn OFH, AL �j Commonwealth of Massachusetts Executive Office of Environmental Affairs AUG 2 2 ���� I Department of Environmental Protection _4 William F. Weld Governor Trudy Coxe Secretary, EDEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 2.11IZ- 0S7- Address of Owner: Date of Inspection:S114 19% (If different) - Name of Inspector: Company Name, Adirresss4anJeYpon;e &mIn P4 �K4 M *-w4 QTtP,PJT" CERTIFICATION STATEMENT. �tA. �8 I certify that I have personally inspected the sewage disposal system at this a dress an tat 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: (/ C lDate: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty -r,1^' 1 ng this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, 9/v/hall submit the report to the appropriate 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 f" = INSPECTION SUMMARY: - _ y GOCheck A, B, C, or D. (J h�^ A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure c 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 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, cracked, structurally unsound, shows substantial infiltration or exfiltratibn, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. . (revised 8/15/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500 i' Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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(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 g- obstruction is removed ,,� distribution box 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE FNA'IRON'h4FNT _ ThesyS.Te , hasaseppKInk and soil-bsorpfioa system► and is wtthirt 1 ec fcn', n f�� orer rnnnly or t,;[,, iter to surface water supply. _ The systen- h:s a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system ha- a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The he_ a septic tank and soi! 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. DJ 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. (revised 6/15/95) 2 � A . Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of ► Environmental Protection William F. Weld, Gowmor Trudy Coxe Secretary, EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: RIG Address of Owner: Date of Inspection:jW111 19 (If different) Name of Inspector: irk J- deml Company Name, Ad ress an a ep oner: CERTIFICATION STATEMENT IV6• j"41111Adfesis.Q`8 6,09— 689 -7116 I certify that I have personally inspected the sewage disposal system at this 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 l Inspector's Signature: F,-� W Q_ Date: sac The System Inspector shall submit a copy of this inspection report 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 system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be ,sew to the s•stem owner and copies sent to the buyer, if apphcabie and tiie appiu�Mi; a�J oii, INSPECTION SUMMARY; , Check A, B, C, or D A] SYSTEM PASSES: I 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 yes, no, or not determined (Y, N, or ND). Describe basis of determination in all in 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 conforming septic tank as approved by the Board of Health. . (revised 8/15/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 a Telephone (617) 292-5500 Ali Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): —X--/,� __, broken pipe(s) are replaced obstruction is removed distribution box 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 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE FNA'IRONNIFNT The,5y47t" hasaseprt .ink and soil Jxorptloa system and is wAirt 1 nn f`c' 2 c f� ; �,o. cn nb nr r.{h tan to surface water supply. _ The systen- h,i, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The sytem ha, a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The �) <tEin ho_ a septic tank and sol! 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. D] 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. (revised 6/15/95) 2 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DI SYSTEM FAILS (continued): _ 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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 the sytem 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 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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propertyddress: -b Tr 4' 9)e. }gndO0er- Owner: 44UvC� Date of Inspection: 8111(f,176 /'1r(,1pG Check if the following have been done: (` Pumping information was requested of the owner, occupant, and Board of Health. t✓ 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. ✓As built plans have been obtained and examined. Note if they are not available with N/A. kThe facility or dwelling was inspected for signs of sewage back-up. .V) The system does not receive non -sanitary or industrial waste flow V 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. i� The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. f� TI•;e facili; c'.'. ^r !a­�d occup2nt5, if different from owne•) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. C SYSTEM INFORMATION Property dress: A10 Dr�i NO- A i - Owner: QlP �tJ4J�2 Date of Inspection: vy - FLOW CONDITIONS RESIDENTIAL: Design flow: 400 all ns Number of bedrooms: Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no):N9 Seasonal use (yes or no):—& -6. Water meter readings, if available: afla Last date of occupancy: f COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste'Holdirig Tank p're'sent: (yes or no)_ t Non-sanifary Waste' discharged to the•Title'S-system:•(ye's or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECOR and source of information: yre 10 , 19 G - i q'� owe System pumped as pan of inspection: (yes or no.)—NO If yes, volume pumped: gallons Reason for pumping. TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: TOVTCA[Ia �� I �•f7. Sewage odors detected when arriving at the site: (yes or no) NO (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` n SYSTEM INFORMATION (continued) Property Address: 2,1c) Owner: �J R%JO V - Date of Inspection: a f , 4•/ 191(p SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP _other(explain) Dimensions: Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:-a—A9 Scum thickness:, O .ii0V4 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.) ' tr". `T'Gak IH a-" . M►iet" e'vwl ouyta-Teva a casr- GREASE TRAP:_ (locate on site plan) Depth below grade:_ Material of construction: _concrete !metal _FRP _other(explain) Dimensions: Scum ti�ickne Distance from top of scum to top of outlet tee or baffle: , Dictanrw from bottom ro ro-, to hntjorr pt ow-! tep o, oatiw Comments: (recommendation for pumpin& condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage-, etc.i II (revised 8/:5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q�t�, SYSTEM INFORMATION (continued) Property Address: al40 A-bbouS' Owner: 35w 9001-%k Date of Inspection: 81m/deft TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Materialof construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) l `tee Depth of liquid level above outlet invert: Comments (note j,'e+ ail(] Ui fiUui u, equa;, ',iGCnkc of sC l > cano er, e'vidence of leak into or o::: of box, e•:c.) 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 8/15/95) M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 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: jnka� overflow cesspool, number: {+� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,et .) IVO 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: Indica;wn of giound.vatej. 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 8/15/95) B SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property dress: ll l ST Owner: Qaw „ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' f9� DEPTH TO GROUNDWATER Depth to groundwater: 4 feet method of etKmmation or approximation: 2 V � Si� C2c%.- ftim .tn ►in 7 t .. ) t - Y AU- .. e,�_— ^ ' - — ^ (revised s/ls/951 9 t - , SMUUB04A/Cqjve4WL01S TOWN OF NORTH TERMINAL NO: +, 52CONSUMER DATE: 06/IG/S,, Acct: 01-2&48000-0 t;??lf"01Ey W.1%,111) P � t B - # ! Book:' ry f'%'� i -'c."1 .C34:>$ l�.t-`l}`:1 j,.,��•-��+�}f�i'�f'}_ -f 1-� i �} i •� c• : 'a :i L1 i sn Cc:# : i-3.3 multiplier . :# ! f r't_ '_ � .>. 4.. Manf Cd: 3 Units; ,^ Size;ipe 3 Type; - 3 Len: "9 I ro �.:: £�:l�sc: • t #it Code: Net. Loc . - Not Pig,n: Cur.. " Serial -0: 00 7460,1iai,_, 775 E i•_''nd J'r-e-y : 7 #_: Yi'_5, f..:• r a M t t t Pi 3 1 1 +t! �� Lt r Consumption Information ------ First 12 Billing 3''#C<f'ft#'s ------ C,?J #.._ .._.._..._....,. 12 �� __......._..._._..._.,_...__ 09 96 20A �i 3/95 23 E� L: a 1.13f'7�� J>�#C.<i`f'1.}'; c_ _...._.__....._._.._.._�'1.3s 06/'4(-a 29 E _12/9 3106/93 / 4 4 � fa^t�'s# !'3L� 32 A 32 E-�- y P 12,193 ,19.a t� J � # - 27}; # � First 12 of a 1-..& � Q�t_eW(: }. t :' Total: (ECC., to Enter Now Mater N' -IY(3ber• 1 �`� W` odi fy,s {11, e1 et:e or. 4 L '97 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:_ o� LOCATION: om Abc LICENSED INSTALLER: SIGNATURE CHECK ONE: CURRENT INSTALLER'S LICENSE# TELEPHONE# !yQ_ A-G�}Cc-7Z�7'4r REPAIR: I./ NEW CONSTRUCTION: 'Rep6oe PIS &Tweesi QKk + D -sr- Ix IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation_ As -Built? Yes No Approval Date: 4z /� t NORTH , ti0 L f� 1 i SACi4kj,., � Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 DISPOSAL WORKS CONSTRUCTION PERMIT 1 Applicant yu. NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair (`•'Jan Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee��' D.W.C. No. TO: FROM: NORTH ANDOVER, MASS 10f /7 19 77 BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at Z® r 134So TT S77-- TT North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 . lsi r E HWqr"%R egC VWS0! �y�dSSbNJ 30 arlan A 1A SIT - V4s Rl 7S X 1,A1 S3 .3-!r —eay .0"-. _41,v _fele . /00,.a3 SOIL PROFILE & PERCOLATION TEST DATA Town? City No.&Street �/aa AZ Lot No. Loc./Subdiv. Plan Owner v / Investigator %Gc.�-`� G; / !J Observer SOIL PROFILES -DATE 1. Elev. ' Elev. 3' Elev. 4-Elev. �0 G i 0 0 0 1 1 1 2 2 Start Saturation 3 3 4 4 5 6 47 �8 9 5 6 7 8 N 21 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 10 10 I 10 I Benchmark Location Elevation Datum Percolation Tests -Date 7 A2 /_ 7 Pit Number 1 2 3 4 S Start Saturation :/3 Soak -Mins. Start Test -Time CO ".2 CO Drop of 3" -Time Drop of 6" -Time Mins.lst 3"Dro Mins.2nd 3"Dro 2. Notes & Sketches on Back Frank C. Gelinas & Associates, North And. 11 j�f / / / � /GGr, ,J� �i�U�-t1 �J O ��j , C � ?: �OaPORA �.♦ APRILVT • 1855 :o Applicant Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 19 APPLICATION FOR SITE TESTING/INSPECTION NA�4� MML (/ ADDR Site Location Engineer Test/Inspection Date and Time Fee -?� • AUU,KLY) �7 EE// IAN, BOA RE Test No. "?//;,/ S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. aG TO: FROM: NORTH ANDOVER, MASS 7 2 19 77 BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at T .S 14 .6 l3 c 7-7- s7— North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 . Osy3'.tSi A �J eg. VgiNfftWeg1,8 itarian f n P Y w7 to/ 3 /77 10 .1 Tovm Ship Re-,,. 7"'t.. October 5 7 46 C1a�k ??d. s 977 Andover, i'Jass Re::,ot i Abbot,, St. Dear Sir AccorcLin.• to the f A1C ti motioned pra ert - sin € rox�d n��n 0X3,/77, the f ubrii +,�;� for absa perctarj he ��)o�7 ,t•=on bed ..,y on test eras made r instfku,ed• Theraf 0 Beet .From �;ho,,2 . he designer � ams osecond Percu =L. nthheis board z.s'„e ruesina Sroi., Cont, ride, beforep tti prO�TdlC:nb'a-ed. p•E e , Yours +ru, ?� 4 5 �6 �7 ,a 9 4 5 ` 6 7 8' 9 4 1 2 3 4 5 4 3S 9 10 ab 5 SOIL PROFILE & PERCOLATION TEST DATA / 6 X0 - j V go, 41 6 q Mins.lst 3"Dro Town/City No.&Street -6-ello C k Lot No. i Loc./Subdiv. Plan Owner ,,;/at.✓r� /'mss Investigatory ,� �:..%!O Observer r f J� SOIL PROFILES -DATE 1' v. �' Elev. 3' Elev. 4'Elev. 0 7aE1 4 7.7 0 0 0 2 2 2 2 3 3 3 3 3 ?� 4 5 �6 �7 ,a 9 4 5 ` 6 7 8' 9 4 1 2 3 4 5 4 3S 9 10 ab 5 iS N 5 v S/ G: 6 X0 - j V go, 41 6 7 8 9 7 8 9 10 10 I—� 10 (—� 10 I� Benchmark Location Elevation Datum Percolation Tests -Date 7 7/ /7y /0! _.7 -'7'1 Pit Number 1 2 3 4 5 Start Saturation.- 3S 9 10 ab Soak -Mins. iS Start Test -Time v S/ G: Drop of 3" -Time X0 - j V go, 41 Dro of 6" -Time q Mins.lst 3"Dro Mins.2nd 3"Drop 2., Notes --&-Sketches on Back Frank C. Gelinas & Associates, North And. 3 FOR 14 - SYSTEM PLA PLUG RECORD Commonwealth of Massachusetts , Massachusetts &stem Pumping Record N•stem Owner J�AovAet-�� Ai am-�— ago Abe Date of Pumping: 5-,-31, p,5- Quantity Pumped: C�gallons Cesspool: No 9 System Pumped by: Contents transferred to Yes ❑ Septic Tank: No ❑ Yes ,0 Date Inspector License #: Commonwe th of Massachusetts Av,-A&O�Massadiusetts System Pumping Record System Owner Date of Pumping. r� Cesspool: No 1_4 -------Yes Ll System Location Quantity Pumped: �CcJ gallons Septic Tank: No U Yes System Pumped by: Fcttedea Ed&t 4 aed License # Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: c c 0 c c 2 Z t R OL v I Q c >1 C c tD I Z tv Q CL I n 0 Z) tA (D Q, 0 Z) C) 0 3 3 O I 0 Q a _ N (D D 0 rt (D 0 >n (D fl.. t c (D O -„ H � � A rt Q A 0 A � 3 D O� i (D D P, O rt O C fD (D 3 rr 8 C f�ii Crtj (D D h cD 0 v D n C a b 31 of 3 1 I I I ) I I 0 Q a _ N (D D 0 rt (D 0 >n (D fl.. t c (D O -„ H /V, Comme Illi ofMassachusetts , Massachusetts System Pumping Record System Omer f P System Location Date of Pumping:— r-��,L� Quantity Pumped: ���gallons Cesspool: No [4--� Yes J Septic Tank: No l._J Yes System Pumped by: 9etredda rtL'eyt"brtma License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: System Other Commonwealth of Massachusetts Massachusetts 1'6 System Pumping Record System Location A s� Date of Pumping: (� � Quantity Pumped: gallons Cesspool: NTJ�-- Yes Septic Tank: No System Pmuped by: 5eit'edoa sil"c0ed License # Conlents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 0 6 64 NN skl 17 ir iZt tA r4 rS �; . ,' • • � �i ' ? �. Vii. '��. \ ` C3a " . _r •� r`^� . Z5 `�`a 4°•.,ti. � �,�c ~``;-., '"y3y Vit., � '�� Gj oZap �Djpr mn a� m �► � � y.Z �pmo^,, �,d� � al �� � � Z Z Z •, tom• � � `�.}, << o v IA 4L AS, ol IA rb w �b �'. �blow ti n oho y0 �a°ym 0 /02 ti n U oho y0 �a°ym 0 o mOil � t1\ rot o�mZ m U