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Miscellaneous - 249 CARLTON LANE 4/30/2018
N i North Andover Board of Assessors Public Access 0 Parcel ID: 210/107.A-0211-0000.0 SKETCH Click on Sketch to Enlarge Community: North Andover PHOTO Click on Photo to Enlarge Location: 2491,43 CARLTON LANE Owner Name: BECK M & A LIVING TRUST, STEPHEN W ELIZABETH A BECK M & A LIVING TRUST Owner Address: 249 CARLTON LANE City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 7 - 7 Land Area: 1.03 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 3208 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 638,300 611,000 Building Value: 439,100 421,400 Land Value: 199,200 189,600 Market Land Value: 199,200 Chapter Land Value: LATEST SALE Sale Price: 1 Sale Date: 06/29/1999 Arms Length Sale Code: F -NO- Grantor: STEPHEN & ELIZ CONVNIENT BECK Cert Doc: Book: 05481 Page: 0281 http://csc-ma.us/NandoverPubAcc/jsp/Home jsp?Page=3&LinkId=468252 Page 1 of 1 7/22/2005 M M Oc 9 O N N r r O 0 o N N J (6 N (D m 6 6:2 x a U C U U U) u°iaf0i' —w a S2wUc O N G C) H M C r � O m 0 @ a C c a E x .... x D H F-- 1-- w O_ Cd G z Z a, p W F- CD z a C9 CD O wz O' Q N J NO N :3 06 Q Q O F- Q Z C9 Y Z O W =m J> U J Q Z p Q= OG DI d W JQ J Qmcn Q = cWJ SCO a 3:m W� N Z a 0 a (A 0 W z •° a T� J C m Z @ 3 0)00 o m m U U M � Go T- J oo N Y C p (n Nw ...0 m °oc°o� r,4 E o U -aD mdU Lj U U a 06 Of O J W W OOf W = o U os a pC N W O y p d LL 00 N (O d (6 C O N N:6 U O_= o J CD aLL M C)� 0 � Z 0 M O N G C) H M C r � O m 0 @ a C c a E x .... x D H F-- 1-- w O_ Cd G z Z a, p W F- CD z a C9 CD O wz O' Q N J NO N :3 06 Q Q O F- Q Z C9 Y Z O W =m J> U J Q Z p Q= OG DI d W JQ J Qmcn Q = cWJ SCO a 3:m W� N Z a 0 a (A O O N (O H U 0)00 U O O O C U r Y Y O > 0— W 00 N (O a z aLL M C)� � Z M O z N p 0(, O LL0 O Q O a Z o c c Q Z N W m m �O �c°)a Ooo o OWN QUO Z o0 1 Ei Z V Z r` �. O ` a' t9 a O v GNLLLO W�N J 0rn0) UL x WN i 7YI- i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 249 Carlton Lane North Andover, MA 01845 �G����® Owner's Name: Steve Beck Owner's Address: 249 Carlton Lane North Andover, MA 01845 G 3 'tpp5 �R Date of Inspection: August 4, 2005 V Name yNameEngineering Services Inc. nor: (please print} New England amin C. Osgood, Jring r. Certified Title 5 Inspector �o NEP Company Mailing Address: 60 Beechwood Drive North Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (3 10 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: : r"7 (f L2, ,Z Date: Q The system inspection shall submit a copy of this mspettion report to the Approving Authority ( Board of Health or DEP) within 30 days of completing this inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 2of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: JE -5_ 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: R System Conditionally Passes: L0 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s) are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced Obstruction is removed ND explain; 3 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 C. Further Evaluation is Required by the Board of Health: _N c? 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 System will pass unless Board of Health determines in accordance with 310 CMR 15.3030)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and (SAS) Soil Absorption System and the (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 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 of the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organize 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner's Name: Date of Inspection: 249 Carlton Lane North Andover, MA 01845 Steve Beck August 4, 2005 D. System 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 overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any Portion of the SAS, cesspool or privy is below high ground water elevation. f Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) /Q2 (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You mqg indicate either "yes" or "no" to each of the following: (The folio criteria apply to large systems in addition to the criteria above) Yes No The system is withk_400 feet of a surface drinking water The system is within 200 fee a tributary to a surf drinking water supply The system is located in a nitrogen se <earea (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you answered "yes" to any questi Section E the system is coni a significant threat, or answered "yes" in Section D above the large system has failed owner or operator of any large system cons' ered a significant threat under Section E or failed under Section D shall up the system in accordance with 310 CMR 15.304. The em owner should contact the appropriate regional office of the Dev&iment 5of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 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 an inspection ? L� Were as built plans of the system obtained and examined? (If they were not available note as N/A) V" Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for sign of break out? Were all system components, excluding the SAS, located on site? Were all 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 difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on; Yes No _1zf Existing information For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design) 4 Number of bedrooms (actual): DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms): -- Number of current residents: q, _ Does residence have a garbage grinder (yes or no): Nc Is laundry on a separate sewage system (yes or no): Al o [if yes separate inspection required] Laundry system inspected ( yes or no): --- Seasonal use: (yes or no): A) a . Water meter readings, if available (last 2 years usage (gpd): Sump Pump (yes or no): Aro Last date of occupancy /', u COMMERCIAIJINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft, etc Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: /J)" N 0 w N Was system pumped as part of the inspection (yes or no): nr v If yes, volume pumped: gallons — How was quantity pumped determined? 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) lnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected wen arriving at the site (yes or no): 7of11 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 BUILDING SEWER (locate on site plan) Depth below grade: ?- © ' Materials of construction: cast iron_40 PVC other (explainl Distance from private water supply well or suction line:_ /p /4 - Comments (on condition of joints, venting, evidence of leakage, etc.): V L PE (s0c3S2 t n i� .N l .i k�A sr% ✓kc%til SEPTIC TANK: (locate on site pian) Depth below grade: 9 Material of construction:—)�..._concrete metal fiberglass polyethylene Other (explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: 1,57 GSA c ro N -r- Sludge Sludge depth: G �- Distance from top of sludge to bottom of outlet tee or baffle: -3 Scum thickness: 0 - Distance ' 'Distance from top of scum to top of outlet tee or baffle: g Distance from bottom of scum to bottom of outlet tee or baffle- 7 - How were dimensions determined: It eA 5. j a e� Sn.UL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Ti4+� IL A-✓ rC-" tiC cc7-F-R I N 0 Y- CANS 1,aN GREASE TRAP:(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from botton of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. 9of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 TIGHT OR HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of constniction: concrete metal fiberglass polyethylene other (explain) _ Dimensions: Capacity: gallons DesignFlow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): O �x c e -re 2to r 7 ti e epi 2 E P c C' ,�-c = ,� e 3 J x 1?P �1 �} �� A-5 PR-r27r I —,-Pe-«a nv. PUMP CHAMBER IU (locate on sire plan) Pumps in working order (yes or no) Alarms in working order (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 9of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 SOIL ABSORPTION SYSTEM (SAS): (locate on site Ulan, excavation not required If SAS not located explain why TYPE ✓ leaching pits number 3 'P s leaching chambers, number leaching galleries number leaching trenches, number in length leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Typeiname of technology: Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc) %2 1,� cel Pcrs two Ks .��02�vt.4L n/v P� C> Pnf e csc= Po'jy- i ti C� AM S 1 L_ � 2 �) N us 4-1, CESSPOOLS: ((;esspool must be pumped as part of inspection) (locate on sire plan) Number and cotion: Depth — top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow (yes or no) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:41 4- --...(locate on site plan) Material of construction: Dimensions: Depth of solids Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A-- q -S 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 249 Carlton Lane North Andover, MA 01845 Owner's Name: Steve Beck Date of Inspection: August 4, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water (-- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record — If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health — explain: Checked with local excavator, installers — (attach documentation) _ Accessed USGS database -explain: You must describe how you established the high ground water elevation: '- �ji4Sl .vt�N� Diz� w . j4(p�� S.^MP 1 UMC. 1�JASl �1;1L'�Z%` l 5 �. � I?j �C � ,..•� U S G-5 A- P s 1 AJ L,- A- —(1 `2, r3tl- CP—a.0E Commonwealth of Massachusetts City/Town ofCkRE _ 1-0 System Pumping Record ytM SV,v` Form 4 rCT 2 0 2009 DEP has provided this form for use by local Boards of Health. Ot erfb",s mp -be used ; 4u4 the information must be substantially the same as that provided her eoZi thts form; ch�cic with your local Board of Health tq determine the form they use. The System Pumping Record m- usi be submitted to the local Board of Health or -other approving authority. A. Facility Information 1. System Locati n: Left side of house, Right side of house, Left front of house, Right front of house, Leff ear , Right rear of house. Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) otic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 91q0If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L. .D Lowell Waste Water Signature of Hauler F5821 Vehicle License Number 4—J(S---©? — Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 NEW ENGLAND ENGINEERING INC August 23, 2005 North Andover Board of Health 400 Osgood Street North Andover, MA 01845 SERVICES RE: TITLE V REPORT: RE: 249 Carlton Lane North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely, 6, Benjamin C. Osgood, Certified Title 5 Inspector 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 HORT#1 O F M = • i _ • off+ - �>�� M �SS�ICMUSEt Applicant Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT Site Location ?--I 'Cr C 2z✓ - •-- Form No. 3 -J -71. P Permission is hereby granted to Construct ( ) or Repair (),fYn Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee Z CH IRMAN, V11 D OF HEALTH D.W.C. No, Town of North Andover of AORTR Ati Office of the Health Department o A Community Development and Services Division 400 OSGOOD STREET ;,�o,�� North Andover, Massachusetts 01845 �SSACHUe°/ Susan Y. Sawyer, REHS/RS Public Health Director 978.688.9540 - Phone 978.688.8476 - Fax CW�"l�FI"qE OF COWtLDrIANCE As of: August 16, 2005 This is to cert that the individual subsurface dzsposafsystem Repaired' — lDistribution Bo.� Only 6y Ben Osgood At 249 Car�ton Lane Yorth Andover, JKA 01845 Yfas been installed in accordance with the provisions of Titfe v of the State Sanitary Code and with the North Andover Board of Yfeafth regulations. The Issuance of this certificate shaft not be construed as a guarantee that the system wiff function satisfactorily. C 91lichefe E. Grant 1TubCu Yfealth Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover Office of the Health Department Community Development and Services Division 400 OSGOOD STREET North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/RS Public Health Director 978.688.9540 - Phone 978.688.8476 - Fax yERI�FICA2tE Off' C091j2'LIANCE As of: August 16, 2005 rIhis is to cert that the individua(su6surface disposal system Repaired(f) —1Distri6ution Oo., Onry 6y Ben Osgood At 249 CarCton Gane North Andover, 9YA 01845 Yfas been installed in accordance with the provisions of Titre v of the State Sanitary Code and with the North Andover Board of Yfealth regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. gvichele E. Grant 1Tu6lic Zeafth Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORT#q Oq 1z ° e 1'tiO O p f 7SSACHUSEt Applicant Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT V ►RE55 Site Location % '-1 'q (- V -r I "��"` / -- --k- Permission -- Permission is hereby granted to Construct ( ) or Repair (KYn Sewage Disposal System as shown on the Design Approval S.S. No Form No. 3 PL—/ -7C P Individual Soil Absorption CH IR AN, B 0 OF HEALTH Fee I L7,5' � D.W.C. No. Town of North Andover Health Department — Date: Location: dz 'S'7 (Indicate Address, if Residential, or Name of Business) Check #: Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing $ ❑ Septic -.Design Approval $ e�'"Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning 3, $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) Ef `, j Agent Initials Health White - Applicant Yellow - Health Pink - Treasurer NEW ENGLAND ENGINEERING SERVICES, INC. 8173 Town of North Andover 8/16/2005 249 Carlton Lane D -Box replacement 125.00 r Ll Checking - Banknorth 125.00 NEW ENGLAND ENGINEERING SERVICES, INC. 8173 Town of North Andover 8/16/2005 249 Carlton Lane D -Box replacement 125.00 Checking - Banknorth 125.00 CVV „ ,,, M Accent Printed Products, Inc.- 888-549.9929 .s TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS Public Health Director )R DISPOSAL I DATE: 2111,1 05 978.688.9540 — Phone 978.688.9542 — FAX NORTN 0 ti a �,SSwCMUg t� RECEIVE - e-mail www.townofnorthandover.com} webs;- 1 2005 LOCATION: 2 4 q C A 2 i. --e N L -AN t TOWN OF NQ�TH ANDOVEh? ON PE �i iEALTH DEPAR—AErv;. LICENSED INSTALLER NAME: V_ �-5 4 MI ,v G QsGo o o J le PLEASE PRINT SIGNATURE: C Q TELEPHONE# 9 78 - 69 6 - 17C 3 4 CHECK ONE: FULL SYSTEM REPAIR: COMPONENT REPAIR (indicate what parts): 0 - F ox * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As -Built Plan. $250.00 or $125 Fee Attached? Project Manager Obligation From Attached? Foundation As -Built? Floor Plans? Yes No Yes No Yes No Yes No FP r� r Approval of Health Agent Date: ($250) ($125) • INSTALLER PROJECT MANAGEMENT OBLIGATIONS i As the North Andover licensed installer for the construction of the septic system for the property at 2 4 ej Cca. C 1.-T'� ,J t -,Cc 6n — relative to the application of dated for plans by dated with revisions dated I understand the following obligations for management of this project: and 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necgssary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may porform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction. steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer &� cn 0 ( Date: cry('( -3 Disposal Works Construction Permit # t1 LETTER OF TRANSMITTAL North Andover Health Department 400 Osgood Street North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 - Fax healthdept(&,,townofnorthandover com - E-mail www.townofnorthandover.com - Website Fpage �7of TO: ) DATE: r� COMPANY: FROM: Pamela Phone: / G� ��RE. / L7 Fax: 15 l/ /�' We are sendi, C? 6`a' � - �` •` OCL A toc LAKO tie, Health Dept. Assistant 0. OCopy o Letter OPlans OOther These are transmitted as checked below: OApproved as Noted OAs Requested OAs Required OResubmit in below, copies for approval OFor approval OFor Review and comment OFor Your Use OSubmit conies for dist. ryG - 3r "a 0 Pools & Septic Systems # HD -0Z Why do I need this approval? Unless the Board of Health approves the location of the proposed pool, the Building Department will not issue a building permit. The Board of Health reviews all applications for residential pools that are proposed for sites with septic systems to make sure that the pool is not being placed on top of the septic system components, on or in the leach area or on or in the reserve area. In addition there are certain setbacks to the septic system and any well on site that must be maintained. What do I need? For the Health Department review you will need the following documents: • Scaled plot plan with house and septic system accurately located; • Plan location of your proposed pool at the correct scale added to the plot plan If you do not have this information in your own files, the Board of Health may be able to help you by providing a copy of your septic As -Built plan. Who do I see? To obtain a copy of your As -Built (the plan that shows your lot, house and septic system as it was bui/4, you may request a copy to be made at the Health Department if one is on file. If you cannot obtain a scaled copy, you may want to request that your septic tank pumper come out and locate the septic system components. A Civil Engineer may also locate the system and can then prepare a certified plot plan. Once you have the plot plan and are ready to site the pool, there are a few rules you need to keep in mind. They are: • In -ground pools must be at least 20 feet from the septic system leach area and at least 10 feet from the septic tank. Aboveground pools must be at least 10 feet from both the leach area and the septic tank. If there is a well on the property, regardless of the well's use, then: Both types of pools must be at least 15 feet from the well. These setbacks include all parts of the pool, such as fences, decks, cement walkways and grading. How do I do this? To start the process you must first go to the Building Department and apply for a permit to install a pool. You will pay a fee and receive some paperwork. You will have to go through the Conservation Commission if you have wetlands on or near your property. It is always wise to check with the Conservation Department whenever you are planning an outside project that will result in excavation of soil or removal of trees. You can, at the same time you are working with Conservation, submit your paperwork to the Health Department for review and approval. If there is a problem with the application or if information is missing, you will be contacted and asked to supply additional paperwork or clarify something on your application. A final approval and issuance of a building permit will depend on the approval of all pertinent departments. Other References: • 310 CMR 15.000 of the State Environmental Code, Title 5 (Download a copy online at www.state.ma.u5Zdep/brp/wwMLt 5pubs.htm) • Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage • #CD- 01 Notice of Intent (NOI) brochure • #PD -01 Watershed Permit brochure Town of North Andover Health Department - Community Development & Services Division This brochure is intended as education of the local permitting process on/y. /t does not cover al1jurisdictions or scenarios thatyour permit application maybe subject to. Permit applications are site specific. Additions -and Septic ## HD -0 Systems Why do I need this approval? The Health Department must approve all applications for additions to houses served by a septic system before the Building Department will issue any permit. This is because there are several things that the Health Department must check, namely: • Does the addition meet setback requirements? • Is the septic system working now? • Where exactly is the septic system? • Will there be more flow to the system? • Does the system currently comply with relevant regulations? • Is the system large enough to handle any extra flow? • Is there room enough on the lot for a new system and a reserve? All these questions address the problem of whether the septic system is or can be made large enough for the maximum number of people the house could hold. An addition of any kind when there is a septic system on the site is considered "new construction". What do I need?: You will need to submit floor plans for the proposed addition along with a complete floor plan of all floors of the house as it currently exists. The two plans should be in the same scale. You will also need a certified plot plan showing the outline of the existing house, the proposed addition, the location of the septic system, and any wells or pools on the site. These should all be to scale. It is also recommended that you have your septic system inspected by a certified Septic System Inspector. It is important that your inspector checks on the size of your septic system as well as how well it is working. Who do I see? See the Health Department if you cannot locate the septic system; there may be a plan on file. See the Zoning Officer to find out if your lot and the proposed addition meet Zoning requirements. Check with the Conservation Department to discover whether wetlands will be a factor in your project. Then submit your entire package to the Health Department for a decision on your septic system's fate. A Civil Engineer could help you with this process. How do I do this?: To start the process you must first go to the Building Department and apply for a permit for an addition. You will pay a fee and receive some paperwork. You will probably have to go through the Conservation Commission process if there are any wetlands anywhere near your project site. If your site is located in the k-ake Cochiewick watershed, then you should check with the Planning Department to see if you need a special permit. If you have submitted your application to the Board of Health, staff can be reviewing it while you are going through other departmental processes. A final approval and permission for a building permit will depend on the approval of all pertinent departments. Other References: • 310 CMR 15.000 Title 5 (You can download a copy of Title 5 at www.state.ma.us/dep/brp/vvwMZtSpubs tm) • Town of North Andover Requirements for the Subsurface Disposal of Sewage • List of properties in the Watershed (in the Community Development and Services office at 27 Charles Street) Town of North Andover Health Department - Community Development & Services Division This brochure is intended for educational purposes only, It does not cover a//jurisdictions or scenarios that -your permit application maybe subject to. Permit applications are site specific. Decks & Septic Systems Why do I need this approval? This approval is necessary for two reasons. 1) A Building Permit cannot be issued unless the Board of Health approves the application and; 2) The Health Department must make sure that the septic system will not be adversely affected and result in a threat to the environment or to the public health. When a deck is added to a house that is served by an individual septic system, the Health Department must review the application to make sure -`that the deck isn't located over the septic tank and the deck supports aren't on the tank or in the leach area. Any one of these conditions could jeopardize the proper functioning of the septic system and/or cause a system failure. What do I need? For the Health Department review you will need the following documents: • Scaled plot plan with house and septic system accurately located, • Plan location of your proposed deck at the correct scale added to the plot plan If you do not have this information in your own files, the Board of Health may be able to help you by providing a copy of your septic As -Built plan. Who do I see? To obtain a copy of your As -Built (the plan that shows your.lot, house and septic system as it was buiitj, you may request a copy to be made at the Health Department if one is on file. If you cannot obtain a scaled copy, you may want to request that your septic tank pumper come out and locate the septic system components. A Civil Engineer may also locate the system and can then prepare a certified plot plan. Once you have the plot plan and are ready to site the deck, there are a few rules you need to keep in mind. They are: • Decks cannot be placed over septic tanks. • Deck supports cannot be placed on a septic tank nor within 5 feet of the tank or line to the tank. • The deck must be at least 10 feet from the leaching area. # HD -0 1 How do I do this? To start the process you must first go to the Building Department and apply for a permit to build a deck. You will pay a fee and receive some paperwork. If you are in the Lake Cochiewick Watershed you should check with the Planning Department about a Watershed Permit. You may also have to go through the Conservation Commission if you have wetlands on or near your property. At the same time you are talking with Planning and Conservation, you may submit your paperwork to the Health Department for review and approval. If there is a problem with the application, such as information being missing, you will be contacted by a staff member of the Health Department. A final approval and the issuance of a building permit will depend on the approval of all pertinent departments. Other References: • 310 CMR 15.000 State Environmental Code Title 5 (Download a copy online at www.state.ma.uVdep/brp/wwMZt5-p ubs.htm) • Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage • List of properties in the Watershed (on the counter) Town of North Andover Health Department - Community Development & Services Division This brochure is intended as education of the /oca/permitting process only It does not cover al jurisdictions, or scenarios thatyour permit app/kation maybe subject to. Permit app/ications are site specific. s LETTER OF TRANSMITTAL North Andover Health Department 400 Osgood Street North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 - Fax healthdept a,townofnorthandover.com - E-mail www.townofnorthandover.com - Website TO: COMPANY: Phone!/ Fax: /// r� j10RT" q 46 to tOt. IeMMta Page / of '// DATE: FROM: Pamela DelleChiaie, Health Dept. Assistant RE: We are sendin you: OCO o Letter OerPlans 004 ill in below These are transmitted as c cked below: OApproved as Noted s Requested OAs Required OResubmit copies for. approval OFor approval OFor Review and comment or Your Use OSubmit conies for dict_ TRANSMISSION VERIFICATION REPORT TIME 07/20/2005 13:12 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATEJIME 07120 13:06 FAX NO./NAME 817275691574 DURATION 00:05:36 • PAGE{S} 11 RESULT OK MODE STANDARD ECM �-��Pti E�ARb14G�/G A"L 5f- 1VIZAgE V Es f W,*A 2,X O u t 1 0,6 S[f Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F. Weld Goismor Trudy Coxe Ssentary, EDEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ^� CERA / CATION Property Address: Address of Owner: Date of Inspection:'` �► k (If different) Name of Inspector: oav S Company Name, Address and Telephone Number: Pfob L, rV S19141r,c CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:" `j �•• Date: �'�' K n 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 sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: 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: Al. 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 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) One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 262-5500 0 Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C %� / SYSTEM INFORMATION (continued) Property Address: Owner: je.2 d"4 .,1 1 � Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' S r 2 e C -t f-ce� r i3liatt S C ,,C*i rj Po gcd ��a e 4?' `P 4 T 0 _ lq g %o D DEPTH TO GROUNDWATER Depth to groundwater:_Lt_feet �^ / method of determination or approximation: w/ -t1;5 e-ctj 6U1 (revised 8/15/95) 9 Property Address: Owner: Date of Inspection: j C1q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) B] SYSTEM CONDITIONALLY PASSES (continued) /1 / W. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required 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: /{ /f. 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 ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 fee! to it surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: �/� 4, 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 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: n Owner: Date of Inspection: D] SYSTEM FAILS (continued): Static liquid level m 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. E] LARGE SYSTEM FAILS: yird d ' • r The following criteria apply to large systems in addition to the criteria above: The design flovti 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 system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall 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) Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION 'edltiii y r. FLOW CONDITIONS RESIDENTIAL: Design flow: gall ns Number of bedrooms: Number of current residents: Garbage grinder (yes or no): Lt Laundry connected to system yes or no): ej Seasonal use (yes or no): - Water meter readings, if ayss}aila I� y / / RE p/ } ter' /� USE r.y�f4J�� i C-42iije 1.1 �1 M r Y V SE Last date of occupancy: rrCC`'�' E= COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 11 keg HC System pumped as part of inspection: (yes or no) T If yes, volume pumped gallons Reason for pumping: ja t' c'(_ /4 d Afle iibva Cts q J7,.ty C1'/«. TV%0F 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: Sewage odors detected when arriving at the site: (yes or no) _ (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST L N. Property Address: 02 q9 Owner: �Z�114 Date of Inspection: Check if the following have been done: 1/ Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ring 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. V' The facility or dwelling was inspected for signs of sewage back-up. 5!e system does not receive non -sanitary or industrial waste flow 71he site was inspected for signs of breakout. /I system components, excluding the Soil Absorption System, have been located on the site. he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or t s, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or ,proximated by non -intrusive methods. _ The facility ov,ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) Property Address: Owner: Date of Inspection: SEPTIC TANK: Ile S (locate on site Ian) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L SYSTEM INFORMATION (continued) '.a 141 e _�—, ,.2 Depth below grade: CO Material of construction:oncrete _metal _FRP —other(explain) Dimensions: /D G , • S rd 31 +' ? " Sludge depth: g# Distance from top of sludge to bottom of outlet tee or baffle: z5 C% Scum thickness:_ IF Distance from top of scum to top of outlet tee or baffle: 7 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.) I -e -c -s r.'aa a CCA#,aIrjoy e�r012 Mc (C_-1 t GREASE TRAP:_ r' (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum m bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION (continued) Property Address: r� q k J �oj� Owner: 444 j -e Date of Inspection: , Cy ir TIGHT OR HOLDING TANK:_ P-41 (locate on site plan) Depth below grade: Material of 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 B0X:jeS (locate on site plan) Depth of liquid level above outlet invert:J� Comments: (note if level and distributicr is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) &U,4 6,10 d v 06j, a/ T /c N- Ala r .) v e y e UiLtPHer ex F fes';4 /kri 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) 7 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q j SYSTEM INFORMATION (continued) Property Address: 02 Owner: 1 a 4 ),If e Date of Inspection:, 1 SOIL ABSORPTION SYSTEM (SAS). f (locate on site plan, if possible; excav tion not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: I�)) Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:a .. leaching trenches, number,length: J �� ��'r leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) G R `C. CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ � (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) Board of Health North An4veriM38. FAn OE I 4q SEPTIC SISTER me TAT.LATICK CHBC$ LIST , 8as.onst LOT ` �'5 G496720W EXCAVATICN OK FAIL 1. Di =ta oe To i a. Wetlanids b. Drains c.. Well 2. Wa er Line'Location 3. No PVC Pipe ie. Septic Tank a. Tess -_Length & To Clean Out Covers b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth Capped Ecnds d. Cloan Double Washed Stone 7. Le -tch Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cwt Pipe to Pit - Both Sides f. Clean Doub7..e Washed Stone .8. No - Garbage Disposal, 9. -yinal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Perc Test d. Elevations e" Water Table 0 I Board of Health Audover,Mass R�-tJ l SUBS', a .,i�t'U�ril..,r. u. rHHCK LIST Flo L) ➢A 16V y LOT APPROM DATE -ZI- i Provided: i - �oP3�ft ro 36_ /E,4roL15.p �2n DISAPPROPED DATE Reasons:>'✓ Title V Reg 2.5 ��� . ��)A Z - _ _ `. - - - FAIL Ob f: The submitted plan must show as a minimumz ) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hales -distance to ties location and results.,percolation tests -distance to ties d design calculations & calculations showing required leaching aro ) location and dimensi6ns of system -including reserve area ) 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 vdthin 100' of sewage disposal system or disclaimer -Planning Hoard files known sources of Water supply within 200' of sewage disposal e _ system or disclaimer ) location of any proposed well to serve lot -100' from leaching facilii (1) location of Water lines on property -10' from leaching facility m) location of benchmark n) driveways a-dispo sale p) no PVC to be used in _construction - - - - --- q) profile of system. -elevations of basement, plumb, pipe, _se_ptic tank, distribution box.inlets and outlets, distrlbutionfield piping and Other elevations ground ater.-elevation-in area sewage disposal system -plan mast be prepared by a�Protes-sJozial`rgineer'-or other �- --- - - professional authorized by lax to prepare such plans &,]'(J) _ _. -- _. Reg 6 Septic �.Tanks (a) eapacities-150% of flow, nater table, tees, depth of tees,_ access, pULTing le"Ib) cleanout ) 10' from cellar uall or inground svTi=ing pool - - (d) 25' from subsurface drains Reg 10.2 Distribution Boxes - - (a) slope greater than 0.08 Reg ".4 b) sump TO: NORTH ANDOVER, MASS !° 19y BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at 413 C19 R- 4- 7`"d IJ /V E North Andover, Mass. $ITE LOCATION i' The grades and construction are as specified in my plans and specifications dated 6y N TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD SYSTEM LOCATION DATE OF PUMPING y > 0-0 y QUANTITY PUMPED CESSPOOL NOZYES SEPTIC TANK NO YES -Z NATURE OF SERVICE: RdUTINE�-ZEMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLID CARRYOVER SYSTEM PUMPED BY COMMENTS: FULL TO COVER BAFFLES IN LACE LEACHFIELD RUNBACK FLOODED OTHER EXPLAIN CONTENTS TRANSFERRED TO TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD D.AIF: 9 . � D'I'EM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) U:\"1'E OF PUMPING: ° QUANTITY PUMPED 'ALLONS (.'I'SSI'OOL: NO V/ YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE ()I3.>FRV:�TI0NS GOOD CONDITION HEAVY CREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER PUMPED BY: C UIIMENTS: —T- �.UNTENTS TRA NS FEIZRED TO: EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED ��RHFR (EXPLAIN) 40 I La (D --q rt (D 0 -h -n h Zo La (D --q rt (D 0 -h -n h North Andover Board of Health 120 Main St. North Andover Ma.01845 Haul Lic. #151 -OOH Install Lic. # 128-0 Date Address 11/1/2000 303 Chester St 11/1/2000 50 Willow Rd 11/1/2000 160 Carelton Ln 11/1/2000 165 Bridal Path 11/4/2000 174 Ingals St 11/4/2000 1062 Salem St 11/6/2000 373 Raligh Tavern Ln 11/6/2000 252 Boxford St 11/6/2000 150 Liberty St 11/6/2000 149 Osgood St 1117/2000 255 Haymeadow 11/7/2000 850 Winter St 11/8/2000 25 Windsor Ln 11/9/2000 249 Carlton Ln 11/9/2000 767 Johnson St 11/10/2000 56 Academy Rd 11/14/2000 Sugar Cane Ln 11/14/2000 250 Abbott St 11/15/2000 195 Winter St 11/15/2000 187 Winter St 11/16/2000 85 Laconia Cir 11/16/2000 86 Willow Ridge 11/17/2000 2135 Turnpike St 11/20/2000 203 Grandville Ln 11/20/2000 391 Pleasant St 11/20/2000 124 Tucker Farm Rd 11/22/2000 394 Boston Rd 11/22/2000 728 Forest St 11/22/2000 18 Johnney Cake St 11/24/2000 106 Rockey Brook Rd 11/24/2000 258 Rea St 11/28/2000 1815 Great Pond Rd 11/28/2000 1420 Great Pond Rd 11/29/2000 266 Lacy St 11/29/2000 1.55 Laconia Cir Andover Septic 47 Railroad St. Bradford Ma. 01835 Gallons Comments 1000 1000 1500 1500 1000 1250 1000 1000 Leachfield Run Back/ Ex. Solids 1500 1000 1500 1250 1500 1500 1500 1500 1500 1000 Extra Solids 1500 1500 1500 1000 1500 1000 flooded 1500 1500 1500 1500 1500 1500 1000 1000 1500 1000 1500 g� y Commonwealth of Massachusetts :a Cit /Town of ra ySystem Pumping Record V 15 all .� Form 4 • TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other f , information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / I 'rear o�house eft / right side of house, Left / Right side of building, Leff/ Right front of building, Left / fight rear of building, Under deck Address • CCity/Town� 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code State Zip Code Telephone umber t k — �- — L 2. Quantity Pumped: a Date Gallons Cesspool(s) ptic Tank EI Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [U/No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G. LSQ LS.Lowell Waste Water If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date U1z - t5form4.doc• 06103 System Pumping Record • Page 1 of 1