HomeMy WebLinkAboutMiscellaneous - 242 FOSTER STREET 4/30/2018i
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 8/25/2014
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair of D -Box and outlet tee
By: Todd Bateson
At:
242 Foster Street
Map 104D Lot 0064
rth Andover, MA 01845
is ce ifi t hall npt be construed as a guarantee that the system will function satisfactorily.
U
MkheIe Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
�v J,
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 242 Foster Street
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
MAP: 104D LOT: 0064
INSPECTIONS
D -Box INSPECTION: 8/15/14
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
1
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank 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
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
X Installed on stable stone base
X H-20 D -Box
❑ Inlet tee (if pumped or >0.08'/foot)
X Hydraulic cement around inlet & outlets
X Observed even distribution
X Speed levelers provided (not required)
❑ Schedule 40 PVC Pipe
Comments:
Commonwealth of Massachusetts j* -i,: L --.V,--- '
City/Town of '
Sysj1
,1L Pumping Record 1"` 31201
Form 4 i TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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, LeftqQar of hou , Left./ right side of house, Left/'
Right side of building, Left / Right front of building, Left f Right rear of building, Under deck
Address C�am- q a
City/Town cstate Tip Code
2. System Owner.
Name
Address (d different from location)
City/Town � sta��� Code ,.
Telephone Number
B. Pumping Record l
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 B-90- If yes, was it cleaned? ❑ Yes ❑ No;
5. Condition of System: (>�
6. System Pumped By.-
Nell
y:Neil Bateson
7.
Name
Bateson Enterorises Inc
Company
contents were disposed:
I nwpll Wmatea Watcr
F5821
Vehicle License Number
t5form4.doe- 06/03 System Pumping Record • Page 1 of 1
7
0
4►
Commonwealth of Massachusetts Map -Block -Lot
'� • 104.D0064
BOARD OF HEALTH ----------- Permit No ------------
North Andover BHP -2014-0677
P•I• FEE
F.I. $125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
----------------------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System.
at No 242 FOSTER STREET
----------------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. 13HP-2014-067 Dated June 25,-2014--------
F-11LE-7
Y
--------- - C0 r-' —
Issued On: Jun -25-2014 `OA OF HEALTH
----------------------------------------------------------------------------------
............................ .............. ""*",*,***,**,""**"",""""""",-,-"*****,****,*"*",111*111I .......
242 FOSTER STREET
Reference No: BHJ-2014-000042
...................................
Permit No: BHP -2014-0677
Department: ...................................
North Andover BOARD OF HEALTH
.........................................................................................
Account No: 1001001.1.5.0510.00
FeeType: ....................................
DWC-Component Repair PERMIT Receipt No: REC-2014-001695
......................................................................................... ....................................
Paid By: Paid in Full On: Wed Jun 25,2014
Todd Bateson ...................................
.........................................................................................
Check No: 8157
Received By: ...................................
Lisa Blackburn
.........................................................................................
DEPARTMENT'S COPY Amount: $125.00
...........................
L........................................................................................................................................................................... j
Application for Septic Disposal S�►stem
TODAY'S DATE
4 Construction Permit -TOWN OF
$ 250.00 — Fuil Repair
NORTH ANDOVER, MA 01845 $425.00 - Component
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* i _
only the tab key epair or replace an existing system component— What? — 01c - 6p -.4E �(� Ta,_
to move your
Cursor - do not
use the return A. Facility Information �[
key.
Address or Lot #
n
rer�.IG:,A�rIP-� u r
citylTown - �f(11 2 5 2014
2: TYPE OF SEPT SYSTEM .
➢ ❑ Pump ravity (choose one) TOWN OF NORTH ANDOVER
'If pump syst attach copy of electrical permit to application*" HEALTH DEPARTMENT
onve
➢ ntional System (pipe and stone system)
➢ ❑ 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)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of biter before DWC issuance)
What is the Make? What is the Model.?
2. Owner Information _
_A Lifiy GLIM j�LQ �� ( r
Name
Address (if different from above) " _
City/Town State Zip Code
g^I� qyy.� �j9vv
Telephone Number
3. Installer Information
--7
Name Name of Company
reAATMnN BfMRPRi
Address 111 AR ROAD
ANDOVERR,, MM A 01810
Cityrrown State Zip Code
qi it ?'Id --A-7-71
Telephone Number (Celt Phone # if possible please)
4. Designer Information
Name Name of Company
Address
City/Town
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
c
660 FTN Application..for Septic Disposal :System
AConstruction Permit=TOWN -OF
ORTH AND OVER, MA 01845
PAGE 2 OF 2
TODAY'S DATE
$.250.00 - Full Repair
$125.00 - Component
A. Fadflity.Information continued....
5. Type- of Building: ED 4eidential 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,1w this Board of Health.
-gq-/t/
Name Date
i
aij Approhly-
Y: (Bo rd of Health Represent.live)
N me rate
Application Disapproved for the following reasons:
For Office Use Only:
1
FeeAttacbed?'
Yes
No
2.
ProiectMariager Obligation Form Attached?
Yis
No
3.:
Ewnp System? Ifso) Attach copv ofElecirrcal Permit` .
.Yes
No
4.
Foundation As Built. (new constructionronly).
Yes
No
(Same scale as approved plan)
S.
FloorPlans? (new construction only).
Yes_
No
A 0dation for ji poral System Construction Permit Page 2 of 2
1
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have to be imAfim • `
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6831
so
Town of North Andover
��'•�,; o :• HEALTH DEPARTMENT
,SSACNU�+t�
CHECK #: ,.
LOCATIO
H/O NAM
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
$
❑
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
$
SEPTIC Sustems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
❑
Title 5 Inspector
$
1
Title 5 Report y
$ ),VU
0
Other: (Indicate)
$
6
Health Agent Initials j
White - Applicant Yellow - Health Pink - Treasurer
�� vvnnnvu��caau vfi1i1�7�7i1V 11 M�7i'iLW
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M"( 242 Foster Street
Property Address
Judy Chmielecki
Owner Owner's Name
—
require for
is North Andover MA 01845 6/17/2014
required for
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
MA
Citylrown State
978-475-4786 S115
Telephone Number
B. Certification
License Number
01810
Zip Code
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 ❑ Fails
❑ Ne ds Further Evaluation by the Local Approving Authority
)),/ A�
6/17/2014
Inspect* s Sign t e Date
JUN 2 3 2114
W
TOWN OF NORI i -i r, ._ J -,'ER
HEALTH DEPAr4T:.ac,,T
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.
****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.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
vel -q
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845
State Zip Code
6/17/2014
Date of Inspection
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:
® 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.
Check the box for "yes", "no" or "not determined" (Y, N, ND) 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.
❑ Y ® N ❑ ND (Explain below):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover MA 01845 6/17/2014
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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
❑ Y Z N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ 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 ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
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
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover MA 01845 6/17/2014
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
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
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 fecal
coliform bacteria indicates absent 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:
Outlet tee,outlet pipe to d -box & d -box needs to be replaced & a riser installed on d -box. Water jet
leach pipes to remove solids.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ® 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 Y2 day flow
t5ins • 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 4 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner Owner's Name
information is
required for North Andover
MA 01845 6/17/2014
every page. Cityrrown
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
❑
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
Z 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 fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
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
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.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
\ %,ommonweauai of 1nassac11u25eLw
a . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Owner
information is
required for
every page.
Property Address
Judy Chmielecki
Owner's Name
North Andover
City/Town
C. Checklist
MA 01845
State Zip Code
6/17/2014
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑
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?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ®
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® 11
in the field (if any of the failure criteria related to Part C is at issue
approximation
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
D. System Information
Description:
Number of current residents:
6/17/2014
Date of Inspection
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft.,. etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
It
❑
Property Address
®
Judy Chmielecki
Owner
Owner's Name
information is
required for
North Andover MA 01845
every page.
City/Town State Zip Code
D. System Information
Description:
Number of current residents:
6/17/2014
Date of Inspection
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft.,. etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
It
❑
Yes
®
No
❑
Yes
®
No
❑
Yes
❑
No
❑
Yes
®
No
Yes
® Yes ❑ No
Current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑ Yes ❑ No
t5ins • 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 7 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845
State Zip Code
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
Pumped 2009, owner
1500
gallons
Measured tank
Inspect tank & tees.
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
6/17/2014
Date of Inspection
® Yes ❑ No
❑ 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
h
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
< ' 242 Foster Street
Owner
information is
required for
every page.
Property Address
Judy Chmielecki
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
6/17/2014
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
28 years old, 9/17/1986, final inspection from B.O.H.
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 1.4
feet
Material of construction:
® cast iron ® 40 PVC ❑ other (explain): —
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" Cast Iron through wall to septic tank, 3" PVC in house, no leaks visible
❑ Yes ® No
Septic Tank (locate on site plan):
Depth below grade: .4
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 4'
Sludge depth:
6"
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Septic Tank (cont.)
MA 01845
State Zip Code
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
6/17/2014
Date of Inspection
27"
511
8e
10"
Tape Measure
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 badly corroded, needs to be replaced. Depth of liquid
at outlet invert. No evidence of leakage. Outlet pipe to d -box has dip in it, needs to be replaced. No
evidence of leakage..
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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:
Date
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Owner
information is
required for
every page.
Property Address
Judy Chmielecki
Owner's Name
North Andover
MA 01845 6/17/2014
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
C
6/17/2014
Date of Inspection
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.):
Evidence of leakage, corrosion holes in d -box. D -box filled with stone up to outlet pipes from
corrosion holes in d -box. Cleaned out d -box. Evidence of carryover, pumped d -box to clean. D -box
cover broken, replaced same. D -box needs to be replaced & riser needs to be installed on d -box
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 or 17
Commonwealth of Massachusetts
` Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 242 Foster Street
Property Address
Judy Chmielecki
Owner Owners Name
information is
required for North Andover MA 01845 6/17/2014
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
z
leaching fields
1 field 27'x 60'
number, dimensions:
❑
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. Leach pipes needs to be water jetted to
remove solids.
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 ❑ No
t5ins • 3113 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 13 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System f=orm - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover
Cityfrown
MA 01845
State Zip Code
6/17/2014
Date of Inspection
D. System Information (cont.)
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.):
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover MA 01845 6/17/2014
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand -sketch in the area below
❑ drawing attached separately
0i^uIt,
140 use,
0 _Soy
� 1 �
i
a = H FS 3
L_(0I 1 t
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
`title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover
Cityfrown
D. System Information (cont.)
Site Exam:
E Check Slope
® Surface water
® Check cellar
® Shallow wells
MA 01845 6/17/2014
State Zip Code Date of Inspection
Estimated depth to high ground water: >5feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 4/4/1985
Date
❑ Observed site (abutting prdperty/observation hole within 150 feet of SAS)
® Checked with local Board if Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Foster Street
Property Address
Judy Chmielecki
Owner's Name
North Andover
Cityfrown
MA 01845
State Zip Code
E. Report Completeness Checklist
6/17/2014
Date of Inspection
Z Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
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
Iocal.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 ht re�rear
`Left/ right side of house, Left /
Right of building, Left / Right front of building, Left Iguilding, Under deck
Address
Cigrrrown state Zip code
2. System Owner.
TIA
Name'
Address (if different from location)
Cityrrown State6 e5 Code
Telephone Number
• i
B. Pumping Record
I. Date of Pumping Date 2. Quantity Pumped:
Gallons .:
3. Type of system: ❑ Cesspool(s) aleptic Tank ❑ Tight Tank L
❑ Other (describe):
4. .Effluent Tee Filter present? ❑ Yews No If yes, was it cleaned?Y
❑ es❑No;
5. Condition of Sys m:
,cam(,
6. System Pumped By.
Neil. Bateson
Name
Bateson Enterprises Inc -
Company
7. Locati e
S.
819PIA6 Hau
t5form4.doa- 06/03
contents were disposed:
Lowell Waste Water
F5821
Vehicle Lioense Number
Date
system Pumping Record • Page 1 of 1
Sam wy R=rd Card Sneratled cn Eri&M41 55 PM by Karen "anco Pop 1
Town of North Andover
Tax Map # 210-104.D-0064-0000.0
Parcel Id 15752
242 FOSTER STREET
CHMIEUCKI, JOHN
242 FOSTER STREET
N. ANDOVER, MA
01845
Sass 101 Single Family Property Type 1 Residential
brdng2 1 Residential Zoning3 l Residential
size Total 1.07Acres
Y 2015
1B Mailinn Index
IawWAddress
Type
Loan Number
Activelinact.
From
Until
*tWEUCKX JOHN
Payor
42 FOSTER STREET
j I. ANDOVER, MA
1845
1B Account-Maint,.
ccoun t No
Cycle
Occupant Name
Activelinactive
Mg Id. 178W.0 - 242 FOSTER STREET
last BHng Date 4!•112014
170465
03 Cyrille 03
Active
1B Services Malnt
1B Meter Maintenance
wmaunt No. 3170465
;anal No Status
Location
Brand
Type
Size
YTD Cons
5505295 a Active
ERT HH RT
b Badger
w Water
0-630.63
0
Date
Reading
Code
Consumption
Posted Date
Variance
6MM14
23
aActual
23
-100%
31'1312014
0
n New Meter
0
4/11/2014
-100%
3/1302014
3751
r Replacement
17
4/11!2014
28%
12611/2013
5734
aActual
13
1/17/20141
-48%
9M2/2013
5721
aActual
26
1011512013
18%
6/1112013
5695
aActual
21
71.1412013
28%
361412013
5674
aActual
17
412262013
5%
12J1262g12
5657
aActual
16
11912013
-86%
9!1262012
5641
aActual
115
1061512012
279%
6112/2012
5526
aActual
30
7/16/2012
0%
311312012
5496
aActual
-6
461462012
-112%
12612/2011
5502
m Manual estimate
48
111762012
9%
14ASG
9613P1011
5454
aActual
48
10113/2011
61%
66762011
5406
aActual
28
762012011
4%
31'772011
5378
aActual
26
411362011
5%
121812010
5352
a Actual
25
1/1262011
-88%
511962010
5327
aActual
218
101158010
539%
618/2010
5109
aActual
33
7/1512010
13%
31102010
5076
aActual
29
4114/2010
-29%
1261162009
5047
aActual
43
1/1262010
40%
9/811009
5004
a Actual
69
101151"1009
122%
6192009
4935
aActual
29
762W20D9
19%
31t6i2009
4906
aActual
28
42962009
5%
12AY2008
4878
aActual
24
Ir202009
-64%
9"'IM 08
.4854
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74
1011012008
68%
6ffirMN
4780
aActual
40
7116r2008
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3610f1008
4740
a Actual
39
4111/2008
9%
1211172007
4701
aActual
38
12262008
-61%
91612007
4663
aActual
79
1061202007
35%
6120/2007
4584
aActual
73
7/2062007
100%
31152007
4511
m Manual estimate
35
4411662007
-11%
12112/2006
4476
aActual
38
111962007
-64%
S M312006
4438
aActual
102
1062062006
128%
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FORM U LOT RELEASE FORM
"RUCTIONS: This form is used to verify that all necessary approvals/permits from
ds and Departments having jurisdiction have been obtained. This does not relieve
applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION
--r
APPLICANT —\ I�iIC�(� l .I�`�y� I P. 1,1' �',i�.!. PHONE %•% S� �O VS -0 SII
I
LOCATION: Assessors Map Number /0J4 Z) PARCEL
SUBDIVISION LOT (S)
STREET -�CS rte-- + ST. NUMBER 7 T
OFFICIAL USE ONLY""
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED l :D W''%
DATE- REJECTED
COMMENTSIV
r _
TOWN PLANNER DATE APPROVED
r1� DATE REJECTED
COMMENTS
FOOD INSPECT �-HEALTH DATE APPROVED
DATE REJECTED
SEP SP-- OR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS �� �, � ; h S" -„ 7<�� �. 7L
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
DATE
11,
�. noo
�y L
oa'�\ rA
�J
r
N
-i
�y L
oa'�\ rA
�J
=L_L —Z) //✓Cr, /! %ASS
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//Y - y—/s'—.R C
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ny < <'�.'I be fii d
4 i e -<.
o. "�rMam
TOWN OF NORTH ANDOVER
MASSACHUSETTS
BOARD OF APPEALS
NOTICE OF DECISION
W'r '
Luau 1 �� r
September. 19, 1994
Date..................... .
Petition No.. • 035-94 Ai:'gtisf '9'9 ' '1'954'&
Septe994
Date of Hearing ........ b e r 13 , ...........
Petition of John Chmielecki and Judith Chmielecki
....................................................................
Foster Premises affected 242 For Street
... ste...........................................................
Special Permit under
Referring to the above petition for a..Section 9,
Paragraph 9.1 of the Zoning Bylaw
.. ....................................................................
so as to permit the expansionof a non-.c.onforming .structure ......... • • • • • • • • • • • • . . .
After a public hearing given on the above date, the Board of Appeals voted to .. GST .... the
Special Per as requested and hereby authorize the Building Inspector to issue a
permit to John Chmielecki and Judith Chmielecki
...............................
for the construction of the above work, based upon the following conditions:
The Board finds that the applicant has satisfied the provisions of Section 10,
Paragraph 10.3 of the Zoning Bylaw and that such change, extension or alteration
shall not be substantially more detrimental than the existing non -conforming use
to the neighborhood.
Signed
rt J
'' GG Wiiliamwan,..0 airman .. Cyy,,c
Walter. Sou1e,..Vice..C.hairman.... .
Robert.Ford .............`.I.............
Scott.Karpinski
.................................
Board o f Appeals
Any appeal shall he filed
within (%n) da;s after tho
rate of i::;J c'. tis Notice
in the Office of th-e Town
TOWN OF NORTH ANDOVER
MASSACHUSETTS
lb BOARD OF APPEALS
***************************
*
John Chmielecki
Judith Chmielecki
242 Foster Street
North Andover, MA 01845
*
***************************
DECISIONS
Petition #035-94
The Board of Appeals held a regular meeting on Tuesday evening
August 9, 1994 continued to September 13, 1994 upon the
application of John and Judith Chmielecki requesting a Special
Permit under Section 9, Paragraph 9.1 of the Zoning ByLaw so as
to permit the expansion of a non -conforming structure on the
premises located at 242 Foster Street. The following members
were present and voting: William J. Sullivan, Chairman; Walter
Soule, Vice Chairman; Robert Ford; and Scott Karpinski.
The hearing was advertised in the North Andover Citizen on July
20, and 27, 1994 and all abutters were notified by regular mail.
Upon a motion by Mr. Soule and seconded by Mr. Ford, the Board
voted unanimously to GRANT the Special Permit as requested.
The Board finds that the applicant has satisfied the provisions
of Section 10, Paragraph 10.3 of the Zoning Bylaw and that such
change, extension or alteration shall not be substantially more
detrimental than the existing non -conforming use to the
neighborhood.
Dated this 19th day of September, 1994
BOARD OF APPEALS
Gt/ '
William J. Sulliv n d�
Chairman
--n•. �x—.r �w�+� 4lras'ity�r�FS .,� _:.ti.. i;.. ,
FORM U - IAT RELF.AM FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: d
C -&'Phone ky-O �w)
LOCATION: Assessor's Map Number 10q-0
Subdivision
treet
Parcel 600
Lot (s) 3AAA
2 • St. Number
************************Official Use Only************************
RE NDATIONS OF TOWN AGENTS:
-- G2 T
Date
Approved
Conservation Administrator
Date
Rejected
Comments
4z (d
Date
Approved
Town Planner
Date
Rejected
Comments
Date
Approved
F ad Inspe/jcl:oor,-health
Date
Rejected
-- )
Date
Approved
G
Septic Inspector -Health
Date
Rejected
Comments
Public Works - sewer/water connections _
- driveway permit
Fire Depart:aenthrYvz_/[��-2�
Received by Building Inspector Date
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l�CA-�J-o N5
FkAL APPIZVAL 04-rC". O -bib APPROJVJ6 6uOr'091-1\16,41
Reg 10.2 Distribution Boxes
I(a) s pe greater 0.08
Reg 10.4 b) s np •
BOARD OF �IEALTH
No.Andover. Nass.
' SUBSURFACE DISPOSAL DESIGN CHECK-" SST
LOT # 3 F'o5T6-0
at
APPROVED DATE�fjC� DISAPPROPED DATE'
Provided: ,�Reasons:
� • NCS LJE�I�w� l:�l�/�'j
Z. �Ai��w !.:E AT �T So �h�0� STiI T
Title V
FAIL
Reg 2.5
The submitted plan must show as a minimums
a) the lot to be served-area,dimensions lot #labutters
b location and log deep observation holes -distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
(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 withiL 100' of sesage disposal
system or disclaimer -Planning Board Piles
(j) known sources of water supply within 'tV' of sewage disposal e
system or disclaimer
(k) location of anT proposed well to serve lot -1001 from leaching facility
r
(1) location of water lines on property -10, 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) maxdmum 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
I(a)
Septic Tanks
capacities -15D% of flow, water table, tees, depth of tees,
-
access, pumping
(b) cleanout
(c) lot from cellar wall or inground swimming pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
I(a) s pe greater 0.08
Reg 10.4 b) s np •
SUBSURME DI&POSAL DESIGN CMK LIST
V
LOT # 34,
APPROUM DATg DISAPPROPED DATE_
Provided: �� Reasons:
IA %+J of SCO S is OF LC-&' ��►(� PeEA Ut7f vgs Ven
Z, 3,i of PE6510+�E pu�2 PIPC e�C�.
jay � %y/�✓,( ,2�� -3 � '�tt � NSE F3 S � 4 �Yv e.�- 1Jcri' 00
Title V
Reg 2.5
Reg 6
Reg 10.2
Reg 10.4
Mao
jc
he submitted plan must show as a m nimum:
) the lot to be served-area,dimensions lot #,abutters
location and log deep observation hoes -distance to ties-- location and results percolation testa -distance to ties
design calculations & calculations showing required leaching area
) location and dimensions of system -including reserve area
f) existing and proposed contours
g) location any wet areas Within 100' 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 within 100' of sewage disposal
system or disclaimer -Planning Board files
(j) knosu sources of water supply within 2001 of sewage disposal e
system or disclaimer
�k) location of any proposed well to serve lot -1001 from leaching facility
,'J) location of water lines on property -10' from leaching facility
location of benchmark
driveways
V^1 garbage disposals
) no PVC to be used �n construction
q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outleta, distribution field piping and
ether elevations
} maximum ground ,rater elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by lax to prepare such plans
Septic Tanks
a) capacities -150.% of flow, later table, tees, depth of tees,
access, pumping
b) cleanout
c) 101 from cellar wall or inground swi ming pool
d) 251 from subsurface drains
4(b)
Distribution Boxes
a) slope greater 0.08
sump
4. IvMikc $ `K as
CA.Ue Inoh�
At t4���s
a,b coval or cAS -
i h our �i� es .. Cv vi � �e Com, IVo .A� � dev� t-�►,cTM.s dr
a- Kwon os .
Board of Health
Nor-th Anifaver,Mass
b
t
sPPROVED DATE
- DISAPPROVED DATE
°rovideds
:asones �`
tle FAIL
=�
.e3g 2.5
a submitted plan must show as a minimums
a
the lot to be served-area,dimensions lot #,abutters
location and log deep observation hoes -distance to ties
c
location and results percolation tests -distance to ties
design calculations & calculations showing required leaching area
location and dimensions of system -including reserve area
f
existing and proposed contours
(g)
location any wet areas within loot of sewage disposal system or
disclaimer -check wetlands mapping
(h)
surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i)
location any drainage easements within 100, of sewage disposal
system or disclaimer -planning Board Piles
0
M sources of vater, supply within 2001 of sewage disposal
system or disclaimer
location of any proposed well to serve lot -1001 from leaching facility
cation of water lines on property -101 from leaching facility
(
location of benchmark
I ML
driveways
arbage disposals
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
10 , er elevations
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
Sqptic Tanks
_4a)
capacities % of flog, water table, tees, depth of tees,
access, pumping
cleanout
t)b
.101 from cellar wall or inground sing -pool
251 from subsurface drains
ag 10.2. Distribution Boxes
slope greater than 0.08
ag 10.4 b) sump
Pit Number
SOIL
PROFILE &
PERCOLATION TEST DATA.
4
S
Start Saturation
•
�North Andover,llass.
No • &Street
Lot
No.
Start,Test -Time __=-
,*
Loc./Subdiv.
Plan
nr
Owner
Invest _gatorL_
-.
Observer
Iins . l st . 3"Dro`
,(Z
Mins . 2nd 3"Dro p3
SOIL
PROFILES -DATE
l•
Elev.—
.?•
Elev.
3. Elev.
4•Elev.
0
1
1
1
1
2
2
2
Ties to Test Pits
.
2
3
3
3
3
- —
4
4
4
4
5�/-
5
5
5
6
6
6
6
7
7
7
7
9
9
9
9"
-
10
1
10
410
10
Benchmark
Location
Elevation
Datum
P rc lation Tests -Date
.wa
Pit Number
1
2
3
4
S
Start Saturation
Soak-Mins.-
oak-Mins. ---Start"
Start,Test -Time __=-
Drop of 311 -Time -
"-Time-Dro
Drop of 6" -Time
Iins . l st . 3"Dro`
Mins . 2nd 3"Dro p3
-
Percolation Rate
A
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