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Miscellaneous - 25 MILL ROAD 4/30/2018 (4)
1 f� 0 3 0 J n O J Q 0 Q 0 / N. LOT & STREET 1 101 MAP/PARCEL CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? (DYES� NO PLAN APPROVAL: DATE o2 �19 7 PP . BY M� r� DESIGNER: /7 L9 ©VI PLAN DATE CONDITIONS i. 1 WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DATE APPROVED ACTERIA I DATE APPROVED BA RIA II DATE APPROVED PLUMBING SIGNOFF WIRING SIGNOFF COMMENTS: FORM U APPROVAL: APPROVAL TO ISS-UUEE _ YES NO DATE ISSUED /kz BY fOJO/Gwy CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: SEPTIC SYSTEM INSTALLATION R r IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: __NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YE NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT DWC PERMIT PAID? DWC PERMIT NO. p 19 BEGIN INSPECTION YES NO: EXCAVATION INSPECTION: NEEDED: YES NO NO INSTALLER:/q, PASSED 7 BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: /'D APPROVAL TO BACKFILL: DATE: BY FINAL GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE: BY 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 beused, 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 hous L Rig�ofho,Left/ rightside of house, Left/ Right side of building, Left / Right front of bul 6ga, Lebuilding, Under deck Address �-- D� t-11" Q Citylrown State Zip Code 2. System Owner. Name Address (d different from loc coN j E City/Town B. Pumping 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): z*1Ce�e h Telephone Number i ,r C,as-f'r, - Date Cesspool(s) — 2. Quantity Pumped eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑Yes Ld'No If yes, was it cleaned? ❑ Yes E] No 5. Conditionef� 6. System Pumped By. - Nell y: 7. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany contents were disposed: t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 Ktk;t11`4!'r_U �JL 0 8 2014 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,&X?Rightear of hous , Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right near of building, Under deck C'tty/Town 2. System Owner. Name Address ('d different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ 4. Zip Code Statel-7<—1 Cod Telephone Number a Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): Effluent Tee Filter present? ❑ Yes to 5. Condition of System: 6. System Pumped By: Neil. Bateson Name Bateson Enterprises Inc Company If yes, was it cleaned? ❑ Yes ❑ No: q � Mi�J=-1 7. L Patae"here contents were disposed: Waste Water F5821 Vehicle License Number Date t5form4.doa 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED _ City/Town of ED System Pumping Record ��uN 8 2013 Form 4 TOWN OF HEALTH R DEP has provided this form for use: by local Boards of Health. Other 13 u the information must be substantially the same as that provided here. Before using this form, ck 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 housRight ea 'of ho , Left / right side of house, Left / Right side of building, Left / Right front of bui ding, Left / Rig rear of building, Under deck CitylTown 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system. ❑ State Zip Code Statst—j�8C`' ,C�T ode Telephone Number &,-- P —(3 --- Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: If yes, was it cleaned? ❑ Yes ❑ No Neil Bateson F5821 b Name Vehicle License Number Bateson Enterprises Inc Company 7. Loc30o @re contents were disposed: Lowell Waste Water Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 M yV v 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 hou , Le ig ea of ho ,Left /right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address a City/Town 2. System Owner. Name Address (if different from location) City/rown State Zip Code TOWN OF NOIRTH ANDOVER HEALTH DPRARTMENT sta '�- ( -8-4Y zittG Telephone Number B. Pumping Record 1. Date of Pumping pate 2._Qu�anb Pumped: Gallons 3. Type of system: ElCesspool(s) Septic Tank ❑Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sys m lw� � �\ 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca ' re contents were disposed: Lowell Waste Water t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Applicant_ )A, -u, Test No. Site Location Lo -r Qyy\� K Reference Plans and Specs ENGINEER Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. �%% d Feet b' CHAIRMAN, BOARD OF HEALTH Site System Permit No. Rs- & Town of North Andover, Massachusetts Form No. 2 eORTq BOARD OF HEALTH o:.� �. •, co y� / 19-_ N � A DESIGN APPROVAL FOR ss"C"°SES SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant_ )A, -u, Test No. Site Location Lo -r Qyy\� K Reference Plans and Specs ENGINEER Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. �%% d Feet b' CHAIRMAN, BOARD OF HEALTH Site System Permit No. Rs- & y Town of North Andover �zd4� Health Department Date: �l, _ Location: -e-5— (Indicate Address, if Residential, or Name of Business) Check #: ���� 194 -29. - 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 $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrasIVSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) 1 1363 Heald Agent_ Initials White - Applicant Yellow - Health Pink - Treasurer COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION gov 'id C, � atvc)6 TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Mill Road _ —North Andover Owner's Name: _David Dellea_ Owner's Address: 25 Mill Road North Andover, Ma 01845_ Date of Inspection 1/25/2006 Name of Inspector: Neil J Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: —111 Argilla Road _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: _1/25/2006_ Thesystem inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 1 014 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Mill Road_ _ North Andover_ Owner: _Dellea _ Date of Inspection: _1/25/2006_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X 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. 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: Page 3 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _25 Mill Road_ _ North Andover— Owner: _Dellea _ Date of Inspection: _1/25/2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance _ "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Mill Road _ _ North Andover— Owner: _Dellea_ Date of Inspection: _1/25/2006 D. System Failure Criteria applicable to all systems: You must indicate "yes" or `%o" to each of the following for all inspections: _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is %i day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Mill Road _ _ North Andover _ Owner: _Dellea _ Date of Inspection: _1/25/2006_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes_ — Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built pians of the system obtained and examined? Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes_ , Existing information. _Yes_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Mill Road_ _ North Andover — Owner: _Dellea _ Date of Inspection: _1/25/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 _440_ Number of current. residents: _4 Does residence have a garbage grinder (yes or no): _No_ Is laundry on a separate sewage system (yes or no): No_ Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter reading: _Yes_ Sump pump (yes or no): _No Last date of occupancy: — Current-COMMERCIAL/INDUSTRIAL Type of establishment: _ Design flow (based on 310 CMR 15.203): ___pd Basis of design flow (seats/persons/sgft,etc.): — Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: — Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped two years, owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_ gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: Inspect tank & tees TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval _ Other (describe): _ Approximate age of all components, date installed (if known) and source of information: _9 years old, 3/13/1997, as built plan_ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road_ _ North Andover _ Owner: _Dellea_ Date of Inspection: _1/25/2006 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _18" Materials of construction: X cast iron _X 40 PVC other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _4" Cast iron thru wall. 3" PVC in house, no leaks visible SEPTIC TANKS: X Depth below grade: _6" _ Material of construction: X concrete _ metal _fiberglass _polyethylene other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 10' x 5' x 4' _ Sludge depth: —3" _ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ Scum thickness: _6" Distance from top of scum to top of outlet tee or baffle: _8" Distance from bottom of scum to bottom of outlet tee or baffle: _18"_ How were dimensions determined: _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 ok. Depth of liquid at outlet invert. No evidence of tank leaking._ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road_ _ North Andover_ Owner: _Dellea_ Date of Inspection: _1/25/2006_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOXES: X Depth below grade _1'_ Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):_D-box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. D -Boz cover broken, replaced it. PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): _ Alarm in working order (yes or no): — Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road_ _ North Andover Owner: _Dellea_ Date of Inspection: 3/25/2006_ SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _X leaching trenches, number, length: 3 trenches 50' long_ leaching field, 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. No sign of ponding to surface. _ CESSPOOLS: Number and configuration: Depth — top of liquid to inlet invert: _ Depth of sludge layer: — Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): _ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 -of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _25 Mill Road_ _ North Andover — Owner: _Dellea_ Date of Inspection: _1/25/2006_ 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. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road - - North Andover_ Owner: _Dellea_ Date of Inspection: _1/25/2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 4' _ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _5/30/1996 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: _Soil test pit data on design plan _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 25 Mill Road, North Andover Owner: Dellea Date of Inspection: 1/25/2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. oriI . .1m I/ r, - ' Neil J. BatVon Bateson Enterprises, Inc. r Summary Record Card generated on 1/27/2006 8:35:19 AM by Elaine Barclay Town of North Andover I Tax Map # 210-107.C-0111-0000.0 25 MILL ROAD DILLEA, DAVID & JANET 25 MILL ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Size Total 1 Acres FY 2006 UB Mailing Index Name/Address Type Loan Number DILLEA, DAVID & JANET Payor 25 MILL ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Property Type Active/Inact. From Account No Cycle Occupant Name Active/Inactive Bldg Id. 13621.0 - 25 MILL ROAD Last Billing Date 11/2/2005 1090298 01 Cycle 01 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 342.56 /1 UB Meter Maintenance Serial No Status Location Brand Type Size 43245941 a Active ENC F.L. ? w Water 0.63 0.63 Date Reading Code Consumption Posted Date 10/27/2005 1348 a Actual 72 11/9/2005 Trouble Code:03 7/26/2005 1276 a Actual 65 8/10/2005 4/21/2005 1211 a Actual 23 5/13/2005 Trouble Code:09 1/31/2005 1 188 a Actual 30 2/15/2005 10/25/2004 1158 a Actual 50 11/15/2004 7/30/2004 1108 a Actual 51 8/25/2004 Trouble Code:03 5/10/2004 1057 a Actual 24 6/8/2004 2/2/2004 .1033 a Actual 23 2/24/2004 10/30/2003 1010 n New Meter 0 10/30/2003 Page 1 i neslaenual Until YTD Cons 0 Variance 14% 136% -6% -47% -9% 157% Commonwealth of Massachusetts a City/Town of a System Pumping Record Form 4 M RECEIVED AUG 2 4 2009 TOOF NORTH AN HEALLTH DEPA TM OTER 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 Lo 'e�. Left side of house, Right side of house, Left front of house, Right front of house, ar of hous�—��Rt rear of house. A Address City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State PW2'Szj Zip Code State/` --:�) Y Zip Code Telephone Number Date 2. Quantity Pumped Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: (� tx- R�k� V-\ 4z5PL�' 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: .L. D Lowell Waste Water Vehicle License Number F5821 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVE� City/Town of System Pumping Record JUL o 7 2008 Form 4 F r TOWN OF NORTH ANDOVER HEALTH DEPARTMEN DEP has provided this form for use by local Boards of Health. er o 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 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. YQ �n 1. System Location: Address 2) v ` q City/Town 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): P,v: s �j N. Zip Code State Zip e & ( - Telephone Number As-ct� Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 8`1Qo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition�(D �y�em� l"C–�) l V,- —k-e�Z 6. System Pumped By: Name Company 7. Locat'where contents_0disposed: t5foim4.doc• 06/03 Vehicle License Number Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts Zusingis \\j City/Town ofE�System Pumping RecordForm 42007 ANDOVER DEP has provided this form for use by local Boards of Health. Other fo�Hdlttie information must be substantially the same as that provided here. Bef, 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 Important: When filling out 1. System L tion: fomes on the computer, use only the tab key Address to move your cursor - do not City/Town State Zip Code use the return key. 2. System Owner: Idl Name +� Address (if different from location) Cityrrown Cod -t Telephone Number B. Pumping Record 1. Date of Pumping bate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Systertl P� . `71 6 Name �J Vehicle �License Number Company 7. t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth. of Massachusetts Cit /Town of IV 0 �� Y RECEIVE® System Pumping Record Form 4 FEB 0 3 2006 DEP has provided this form for use by local Boards of Health.. TheYS�r�g*'i'y'Ltge ord must be submitted to the local Board of Health or other approving a that' - A. Facility Information Important: When filling out 1. System Location: A ;i forms the �, computer, use �-'G� t only the tab key Ad ss to move your cursor - do not use the retum Cityrrown State Zip Code key. 2. Syste wn r. Name �I Address (if different from location) . City/rown State Zi ' . p Code" W Telephone Number B. Pumping Record fi. Date. of Pumping Date 2. Quantity Pumped: Gallons I Type of system: ❑ Cesspool(s) ❑--S—e—ptic Tank ❑Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes if yes, was it cleaned? El Yes ❑ No 5. Condition of System: 6. System Pumpe y NamVehicle License Number Company -- . 7. Loc "on where co ` nts were disposed: 5tgnat!ure �f Hauler h.ftp://www.mass.govidep/waterlapprovalt/t5forms.htm#inspect t5form4.doc• 06/03 Date System'Pumping Record • Page 1 of 1 MERRIMACK ENGINEERING SERVICES INC. Engineers • Surveyors • Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 (508) 475-3555 Fax (508) 475-1448 TO&fQ4 F�C 144 (p f A I �-t S-t-- kjotz-rg A)j.Da✓,�F-Z, t -J A . O I gzIS WE ARE SENDING YOU ❑ Shop drawings ❑ Copy of letter ILRYTIEn OIF V E s MMUTT1d DATE 2-3- 97 JOB NO. ATTENTION l�> ^A 77 rr ^ V 2TA �Z ll�ff RE: Fey, Ll�j )F -�•D S ❑ Attached ❑ Under separate cover via the`following items: .-` ElPrints ❑ Plans [ISamples ❑ Specifications ❑ Change order ❑ COPIES DATE NO. DESCRIPTION Fey, Ll�j )F -�•D S THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ For review and comment ❑ ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS 9A)-�0x., �-foTl= R oto LJ Rgh QS " 1 -S-b FWI ` COPY TO SIGNED: if enclosures are not as noted, kindly notify us at once. FORM U - VERIFICATION 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***************** APPLI CANT : VAV %D "VR"E� —.YES fel LOCATION: Assessor's Map Number Subdivision Phone 1-:05 725 3Co30 Parcel Lots)_ Street F,%O,&fl St. Number 2_S ************************Official Use Only************************ RECOMMENDAT ON TOWN AGENTS: :x' 7 t Date Approved 114iJ Conservation Administrator ,/ / �jDate Rejected Comments CgOC 7) Z fh1°S i�Gr q�/�ta�;�� c'lYj�h; � wet ICR C&W - Town Planner Food Inspector -Health r Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved a Date Rejected Public Works - sewer/water connections ���Af b 7 - driveway permit 1 rll, I 7 ASF ire Department ICRJ%� �-W � TV �e.l d2, '� In STq rl.►T•� Received by Building Inspector _ X217M a, L 6ja,er Date MERRIMACK ENGINEERING SERVICES INC. Engineers • Surveyors • Planners, ;,1--+:� - r 66 Park Street0�''�' ANDOVER, MASSACHUSETTS 01810 (508) 475-3555 �p�12 9 t997 FAX (508) 475-1448 TO BOA Rb o1= N EALTH 1 Town OF M6"( Ak(b6\16 Z ` OWQ HAUL A)j,iiF--x t LI& HAIL �T= WQJ- f A),jDavl~2, MA. O18�lS' NUMBER Page No. of Pages OF 14TTAL DATE 1-Z-7-97 ATTENTION .SAJjD 2TA P—Q- f n RE: L I 1 1LL IWAD WE ARE SENDING YOU Attached _ Under separate cover via the following items. Shop drawings Prints _ Plans Specifications _ Samples — Copy of letter _ Change order Other: COPIES DATE NUMBER DESCRIPTION .3 F -r=\/, 1-2-7-97 PL KI Of= svgsui-FlA69—:E Dts-po,.qgL 9YjTEr- THESE ARE TRANSMITTED as checked below: For approval _ Approved as submitted _ Resubmit copies for approval —For your use _ Approved as noted _ Submit copies for distribution = As requested _ Returned for corrections _ Return corrected prints For review and comment _ Other FOR BIDS DUE/DATE: _ PRINTS RETURNED AFTER LOAN TO US 3EMARKS > l7 ,u�Dy J i P�rA �S R f7.,� lZt.v� s�.p � � Pa✓�Z Yvv2 (1yEvI �t,,� Z.�rrE�'Z.. DATED 1- G- �J'7 AL�o FOR. A WWI SE D HOUSE t4Yvvi CAU— U— 1 F A "vC' �-t�S 1 I o�1S, 1�+t9 g K� I SIGNED rZ_ H enclosures are not as noted, please notify us at once. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:_3 - `) - 9'-/ CURRENT INSTALLER'S LICENSE# LOCATION: (")+ L} P-1 � � qrna LICENSED INSTALLER: F P, e, i I SIGNATURE: TELEPHONE#'� CHECK ONE: 91Z.11 I. NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes :� No Approval � 7� Date: - TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 3' 1-1,1" TEM SYSTEM LOCATION (example: left front of house) b1,e2,j5AF DATE OF PUMPING: 3" QUANTITY PUMPED r GALLONS CESSPOOL: NO �' YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: SEPTIC TANK: NO YES r1c EMERGENCY CONTENTS TRANSFERRED TO: G, L FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) Flo t•14R 13 2001 Town of North Andover t N°RT OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES ° 146 Main Street ♦ 1Q North Andover Massachusetts 01845 .a �q�TED �P` •(G WMLIAM J. SCOTT Director January 6, 1996 Mr. Les Godin Merrimack Engineering 66 Park Street Andover, MA 01810 Re: Lot 4 Mill Road Dear Les: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. No benchmark within 75 feet of system. (3 10 CMR 15.220(9)) 2. Wetlands disclaimer missing. (N.A. 6.020) 3. No foundation drain shown. (N.A. 6.02V) 4. Elevations of perc tests missing. (N.A. 6.02j) 5. Gas baffle on septic tank outlet tee missing. (3 10 CMR 15.227(4)) 6. Any old wells within 150 feet of system? If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S., { Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 DATE /1? BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE ($lp b PERMIT # 0e APPLICANT h�C�EdJ �'EIGtiC/� ADDRESS 9,96 rvevP16c ENGINEER_/J, C,7 �/J'% (gUl�/� ADDRESS iq q 7,,gk4 /tklOoVel< PLAN DATE 1111- h'6 CONDITIONS OF APPROVAL: APPROVED DISAPPROVED Sheet of DATE RECEIVED ASSESSOR'S MAP /Q % G PARCEL # LOT # 4 STREET # REVISION DATE Lo CAI, 7-16 C � 4 C�� �1//� ria �r✓ s ©/=' ���� 7-i�-757s 1q"5s 11v 6 _ ( A/119, 61 o a &V 17-1 ����la �C9✓uYST��O ae ; /SAP, M / A� PLAN REVIEW CHECKLIST ADDRESS ! DT 4- A11 _/ eh ENGINEER��,L'�'_/i�i G GENERAL 3 COPIES L� STAMP. LOCUS 6--' NORTH ARROW -6 --'SCALE L--- CONTOURS/ PROFILE SECTION Ll BENCHMARK SOIL & PERC ELEVATIONS WETS. DISCLAIMER WELLS & WETS k WATERSHED?,46 DRIVEWAY(Elev) WATER LINEc� FDN DRAIN SCH40 G--' TESTS CURRENT? (/ SOIL EVAL U M • uF.26sA) SEPTIC TANK FIRST 2' LEVEL STATEMENT / MIN 150OGy .17 INVERT DROPy GARB. GRINDER_j0_(2 comps P +200 ) 10' TO FDN L/ MANHOLE 1--' ELEV `� GW 0'� # COMPS. GB� D -BOX SIZE_ 7 # LINES FIRST 2' LEVEL STATEMENT INLET 1- �o`Z - OUTLET o't 6 • - _ / ( 2" OR .17 FT) TEE REQ' D? 106 LEACHING / MIN 440 GPD? RESERVE AREAy 4' FROM PRIMARY. ?�� 20 � SLOPE Nor if_�a - 3..T'_40�C'�- 100' TO WETLANDS X100' TO WELLS7 . 4' TO S H.GW c� (5'>2M/IN) geC p Z 20' TO FND & INTRCPTR DRAINS I� 400' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY 2---- MIN 12" COVER BREAKOUT MET? L,--' TRENCHES MIN 440 gpd V SLOPE (min .005 or 6"/1004'-_�SIDEWALL DIST. / 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHES?!/ IN FILL?'f__� WIRT BE 10' MIN.L'--- 4" PEA STONE?aj` - VENT?-- (>3' COVER; LINES >50') BOT + SIDE d X LDNG `�_ = TOT ��� (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1996 by S.L. Starr LOCATION: NEW PLANS: SEPTIC PLAN SUBMITTALS $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: 1 �0' DESIGN ENGINEER: WiV \ When the submission is all in place, route to the Health Secretary MERRIMACK ENGINEERING SERVICES INC. Engineers* Surveyors • Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 (508) 45.3555 Fax (508) 475-1448 t TO 1-6A I D OC H 156li I H Tat,&( off' MMR �4wvrF- WE ARE SENDING YOU ❑ Shop drawings ❑ Copy of letter ❑ Attached ❑ Under separate cover via IOV`1.1 M @1P U ° M1NI UIVULM DATEJOB 1 I-Zt—� DATE NO. ATTENTION 56141) 2 -FA -M RE: Lo7- 4 N14-4., 008D eu5x-� KaL�Jf5z- t TOWN OF NORTH ANDOVER/ QrJAp CAI TW f the ufollowing,items: lid Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Change order ❑ COPIES DATE NO. DESCRIPTION 1 �-12- A-� OF flr) . THESE ARE TRANSMITTED as checked below: (XFor approval ❑ Approved as submitted ❑ Resubmit REMARKS COPY TO ❑ For your use ❑ Approved as noted ❑ Submit ❑ As requested ❑ Returned for corrections ❑ Return ❑ For review and comment ❑ ❑ FORBIDS DUE copies for approval copies for distribution corrected prints 19 ❑ PRINTS RETURNED AFTER LOAN TO US �11-I ►s 1 S R A.C11-0 IT6a CAU, t r ALY OcA 10)4C SIGNED: /f enclosures are not as noted, kindly notify us at once. V FORM 11 - SOIL EVALUATOR FOR.11 Page 1 No . .................... :............ ..... Date.,7. Z6-16....... Commonwealth of Massachusetts K102TH &ND5,vE:lZ , Massachusetts Performed By:.... WALL-irk.'i ..... ................................ �'TN Witnessed By: SA4D RA M— Oz .................. ......... t ; ^ :. .......................... I.. ...... .. ................. . Laation Address or H161, 06AD 0..'. Mr., La N yy��H Address. and qzo rV fLkt AGS i �/i�'` [� }j A 'Ibznl " O- Telephone N NO, Auwv CL9 : P—i 1 • Q I �i S-� 107 - G `i. L . New construction NCJ Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes 5 Year Published Publication Scale i.. rSi34b Soil Map Unit ! Drainage. Class ..C.... Soil Limitations....SGu.t1.................. ...... ..:.......................... ........ ................... Surficial Geologic Report Available: No Yes ❑ Year Published ................... Publication Scale .......... GeologicMaterial (Map Unit)....................................................................................................................................... Landform............................................................................................................................................................................................................ Flood Insurance Rate Map: ZSooN$ 000&C (6 -Z -q>) 20J-ccr- x Above 500 year flood boundary No ❑ Yes lJ Within 500 year flood boundary No z Yes ❑ Within 100 year flood boundary No LJ Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) .....t..1.. loti f Wetlands Conservancy Program Map (map unit) .......:-`. ............................... Current Water Resource Conditions (USGS): Month .......l.y Range : Above Normal ❑ Normal lo/ Below Normal ❑ Other References Reviewed: C,9S ,EE HA-P-'S,� I a 'K 2- Dee 2- FORM It - SOIL EVALUATOR FORM Page 2 On -site. -Review Deep Hole Number j. ... �i Z... Date:S'39.-1?6 Time:Weather CWT -4417 1 .../Q. Location identify on site plan)...:..................................:........................................................ ............�........................................................................ Land Useom........ Slope Surface Stones...=........................................................ Vegetation..... F--1X>-:........................................................................................................................................................................................................... Soil Mottling Landform......VkM P?41A...................................................................................... Position on landscape (sketch on the back)......................................................................................................................................................... Distances from: Open Water Body ....f.00:t.. feet Drainage way .lgP:f. feet Possible Wet Area .j.DO,t... feet Property Line ....7/..f feet Drinking Water Well .1.U0 t feet Other ...... ...... ...... ........... I... DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) AP Sr�uay J -0A1- 1 GZ�f Al' =)OyRS /6POCWTS I41s1,,F,, FecA&-f- F'LAC Rooi S W110 6RAV, Iy "/,, c066(ES i`)ass���,r=a,�ttl3c� �7t9Fw1i>aT �lQt� i S / V Coti$l�C Or- fir -0, �A P I I'= 2' �w FS>C ?O `l2 S�(6 Flue VZOTS F6���f3i� San rife) Ni =loves/g S "�� GQAL F - Lo = s y 6,/3 S °» 916"(58 Parent Material (geologic)......TILL.................. Depth to Bedrock: 1... .......... Death to 6toundwater: Standing Water in the Hole:Nc4o3'� Weeping from Pit Face: I•�vJ-E / � + Estimated Seasonal High Ground Water:.2`�.. �z.�/ T . . FORM 11 - SOEL EVALUATOR FORM Page 3 Determination for Seasonal High Water Table Method Used: Depth observed standing in observation hole .................. inches ❑ Depth weeping from side of observation hole ................... inches E Depth to soil mottl s"Z4"/Z.` "inches ❑ Ground water adjustment feet Index Well {Number .................. Reading Date Index well level Adjustment factor.....` `.... Adjusted ground water level .................................... A. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth- of naturally occurring pervious material? �— Certification I certify that on (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature FORN112 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS "S / LOweZ , Massachusetts Percolation Test Date: Time:......i.-..P``�. Observa ',)n Hole # J Depth of Perc 34-1 Start Pre-soak End Pre-soak f Z 20 Time at 12" Time at 9" i , �0 Time at 6" Time (9.._6") Rate Min./Inch Site Passed Site Failed F] I / ............................................................... ............................................ ............................ I ...................... Performed By: C, Obi j Witnessed By: BALD ZA SA F2- Comments: .. .................... ............................ ............................................... .-.__.......... :..... ..... ........................................ ............. ... ....... ... . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Mill Road Andover_ _North Owner's Name: Joseph Krol_ Owner's Address: 25 Mill Road_ North Andover_ Date of Inspection: 3/1/2001_ 3 200, Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: Argilla Road_ ' _111 _Andover, Ma. 01810_ r Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F's Inspector's Signature: Date: _3/1/2001_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Mill Road_ _North Andover— Owner: Krol Date of Inspection: 3/1/2001_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X 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. 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Mill Road_ _North Andover— Owner: Krol Date of Inspection: 3/1/2001_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: • k Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Mill Road_ —North Andover - Owner: Krol Date of Inspection: 3/1/2001_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or `fid' to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 day flow _NoL Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 31.0 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or `fid' to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Mill Road_ _North Andover_ Owner: Krol Date of Inspection: 3/1/2001_ Check if the following have been done. You must indicate "yes" or ' nW' as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? _Yes _ Has the system received normal flows in the previous two week period ? _ _No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes_ _ Existing information. For example, a plan at the Board of Health. -- No_ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Mill Road_ North Andover - Owner: Krol Date of Inspection: 3/1/2001_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4` Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _440 Number of current residents: Does residence have a garbage grinder (yes or no): _No_ Is laundry on a separate sewage system (yes or no): _No_ [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter readings: -June 98 to June 00 = 36,000 W x 7.5 = 270,000 Gals. / 730 days = 370 Gals. / Day_ Sump pump (yes or no): -Nom- Last o_Last date of occupancy: - Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sg8,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: _Unknown, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank _ Reason for pumping: _Inspect tank & tees._ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool. _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed and source of information: _4 Years old. 3/13/1997 As built plan. _ Were sewage odors detected when arriving at the site (yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road_ _North Andover_ Owner: Krol Date of Inspection: 3/1/2001_ BUILDING SEWER (locate on site plan) X Depth below grade: " 22 Materials of construct_ion: _X_cast iron _X_40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron thru wall. 3" PVC in house. No leaks. _ SEPTIC TANK: X locate on site plan) Depth below grade: _10" Material of construction: —X—concrete _metal _fiberglass __yolyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): T (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth:.6" Distance from top of sludge to bottom of outlet tee or baffle: 21" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: _15" How were dimensions determined: _Subtract scum & sludge depth to tee length. 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 & outlet tees ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road_ North Andover_ Owner: Krol Date of Inspection: —3/l/2001— TIGHT /1/2001 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in. working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): –D -box level & distribution equal, has flow levelers. No evidence of leakage. Evidence of carryover, pumped d -box to clean. _ PUMP CHAMBER: (locate on site 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.): Page 9 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road_ _North Andover_ Owner: Krol Date of Inspection: 3/1/2001_ SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: X leaching trenches, number, length: _ 3 Trenches 50' long_ leaching fields, 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.): No hydraulic failure. No sign of ponding to surface. _ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 0 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mill Road_ _North Andover— Owner: Krol Date of Inspection: 3/1/2001_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate (check) all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _5/30/1996_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per design plan test pit data. _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 25 Mill Road, North Andover Owner: Krol Date of Inspection: 3/1/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. C3 CO aso dCA Z 0-* C C) D CL CL q CA O so CD CLccl cr CD CD 0 CD ww a. C CD CO) CD CL CA cc CD a - CO) to �* .0 �* c =r -1 0 =Wccr am Co Cos C-) CL C.) co CD . c O =r.0 01 0) "F CD =r CL CL CD CD 0 CA 0 CD A 0 ! S. ICW7 0 LA. C2 :&C3 CD nSr = 'a CA 0 4C CD CD 7 0 CD CL. CD Co CA C4) CD 03 CA CD 0 C.) CD 0 CA CD C.j CD CD CA CD CD cm CL C-) C2 tt C/) C/) 0 CIA 0 0 C r- al 0 CD CD CD Pool cl) 0 cc 14� I 1� \o 'A cc c CO CD to �* .0 �* c =r -1 0 =Wccr am Co Cos C-) CL C.) co CD . c O =r.0 01 0) "F CD =r CL CL CD CD 0 CA 0 CD A 0 ! S. ICW7 0 LA. C2 :&C3 CD nSr = 'a CA 0 4C CD CD 7 0 CD CL. CD Co CA C4) CD 03 CA CD 0 C.) CD 0 CA CD C.j CD CD CA CD CD cm CL C-) C2 tt C/) C/) 0 CIA 0 0 C r- al 0 K- A rD 0 CD CD Pool 70 :� �; X CL w CD go 0 0 cc 14� I 1� to �* .0 �* c =r -1 0 =Wccr am Co Cos C-) CL C.) co CD . c O =r.0 01 0) "F CD =r CL CL CD CD 0 CA 0 CD A 0 ! S. ICW7 0 LA. C2 :&C3 CD nSr = 'a CA 0 4C CD CD 7 0 CD CL. CD Co CA C4) CD 03 CA CD 0 C.) CD 0 CA CD C.j CD CD CA CD CD cm CL C-) C2 tt C/) C/) 0 CIA 0 0 C r- al 0 K- A rD 0 CD Pool 70 :� �; X CL w CD go 0 0 cc 14� I 1� \o 'A cc c CO I: to 4 n tG f 0 is. CL CA is C/) gS-ll too O Job =f-4 C m M m bo to �* .0 �* c =r -1 0 =Wccr am Co Cos C-) CL C.) co CD . c O =r.0 01 0) "F CD =r CL CL CD CD 0 CA 0 CD A 0 ! S. ICW7 0 LA. C2 :&C3 CD nSr = 'a CA 0 4C CD CD 7 0 CD CL. CD Co CA C4) CD 03 CA CD 0 C.) CD 0 CA CD C.j CD CD CA CD CD cm CL C-) C2 tt C/) C/) 0 rayC/) 0 0 C r- al 0 K- A rD 0 70 :� �; X CL w CD go 0 M () C/) tz n 1\1n 14� I 1� \o 'A 'z 0 c TOWN Op NORTIM ANDOVZR 6ZWAG9 DWOM ""M iNgrALLAT1O14 CRRt'R+tCATION boM•d r t a= L( FAIL4, A wn d � e "'�' � Naetb Andavet Hoard cf �pe�+� � 9Y� , t7rlp � � •d . •ntqa �e wee anew iFof ga 11e qM�m Nee inelelled in eMc0ldeoee ww the pro�vldM of 314 CMR 15.000, Twig 5 b j ad fir" wd baud �i �' trip► the epprnwd pHn. r+epne�ai as t w A&WU mebmNbm Wfloo the Road a�E{eelb. i>Y1tr1�. SiOf! Lie. M• Debt; Deem�� KORA DANIELS CIVIL No. 37752 s: Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH March 14, jx,1997 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X) or repaired ( ) by Michael Reilly INSTALLER at Lot 4 mii i xoact, Nor n Andover, NLA 01 845 SITE LOCATION has. been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 888 dated November 16J9 96 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HE.ALTW TOWN QS NORTH ANDOVER SWAGS DWOM SYSTEM D(eTALLATWW czRv +[CATION .M nedrnlgj-d b aW a4' data Serie Dirpoml K) wol�eoted; t ) eepaleed� by MitiWA91- 10"d 0 _, eun6Emeaoe wii Ow Naft Andom Bma oeHMA pbm tion i N'pw The�� js � cafamum with t ai wed as � �ed per. Mmw bomw d w n wa � dwbstpev�vidoa� of 310 C'kQt 13,01A S ioal niAV wm alMlo�, moa vomW 7'w%* 00 epprO OWL �Y ape�sai m lWNAvM *fid b. Wmi�t dta be 3oad otti . Lie. N• _ u�ac 3-ZO-'! �Dedr . C,, � DANIEL. KORAVOS CIVIL No. 37752 Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH r NORTH 1 �T 19 F 9 DISPOSAL WORKS CONSTRUCTION PERMIT �,SSACMUS S� Applicant Y, A DRESS TELEPHONE NAME Site Location Permission is hereby granted to Construct (%/or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. r _ Fee I A 1 RMA1q, BOARD OF HEALTH D.W.C. No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH O LED q " 646 OL 0-6 19 9C APPLICATION FOR SITE TESTING/INSPECTION ADRATED PPP �h �SSACHUSE� Applicant NAME TELEPHONE ^ADDRESS YLV Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee 4 �'� Test No. 01,-4— S.S. 1,-4— S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts ,HT1 BOARD OF HEALTH `ED '646NO\ � APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant k . NAME ADDRESS TELEPHONE Site Location Engineer - NAME ADDRESS TELEPHONE Test/Inspection Date and Time �- CHAIRMAN, BOARD OF HEALTH Fee T , Test No. S.S. Permit No. - D.W.C. No. C.C. Date Plbg. Permit No. eaA: P,�'Lmc, 1000. 7 41, 4 FORM 11 - SOEL EVALUATOR FORINT Page 1 1. ' No... .................. : .......... : ...... DateTZ67%a Commonwealth of Massachusetts �M-1714 A"D6Vr:_Z Massachusetts Soil Suitability Assessment fOn-site Sewage Disposal Perfbimed By: ..... WILL-1,A-t'l ..... W.FIZOSAV .................... ............ ................. Witnessed By: SAX4DIZA.. ..... ....... A........................................................................................................................................... ..................................................................................................... L=ion Addms or H16(, 06A 0 *T" .6 -Nam. HFL94 M • 95UM5Z L'MIMI, Ind LZd 7u 2u01 S?"` A vno" or- Tele*n.e NO, A".Dovce, mict, o j6qs-- 10 New Construction' Repair ❑ Office Review Published Soil Survey Available: No 0 Y e s 6blished Publication Scale .. ............ Year P .091 ... Public . Soil Map Unit. .. ... .. . . ... ........ Drainage Class ...�� ...... Soil Limitations ... . ........... .................................................................. ...... Surficial Geologic Report Available: No Yes El Year Published .-..: ............ Publication Scale ............ ... GeologicMaterial (Map Unit) ...... ...... . .... .................... . .. ................................. ...... ................... ...... Landform...................................................... ...................................................................................... ............ ............ . Flood Insurance Rate Map: Z5_006 000&C_ (6-7-q5) 2.�L4C' X Above 500 year flood boundary No ❑ Yes Within 500 . year flood boundary No IJ Yes El. ❑ Within 100 year flood boundary No LJ Yes wetland, Area: National Wetlanu i11Vt11LU1y Map (map unit) ........... . ...... .......... Wetlands Conservancy Program Map (map unit) ........ 7 . ........................................................................... H11 Current Water Resource Conditions (USGS): Month. Y Range Above NormalF Normal Below Normal ❑ A 3S U t--7 Other References Reviewed: V,9.4,f. ".AP -S 41 J "IRM I I - SOIL EVALUATOR FORM Page 2 On-site - Review Deep Hole Number )..f Z... Date:S.SO.7(76 Time:.R.M— ... Weather 0v25ZCoIST_..._.7Q 0 Iocati6 (identify on site plan) ...................... ............................ .................................................................................................................................... Land Y se Slope M Surfacr Stones ............................................................. Vegetation.......... ..... ........ .. ................................................................................................................................... LandformWM.4�-4 ........................................................................... Position on landscape (sketch on the back) ................................................ : ................... I ......................................................... Distances from: Open Water Body ....%00 t- feet Drainage wayJAPt- feet Possible Wet Area feet Property Line feet Drinking Water Well f ee't Other ...... ........................... DEEP OBSERVATION HOLE LOG Depth from Surface Unches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) 0 Iz AP F.S.L. It 70 S A jja-f sf IIZ44 IZS/q Co E\1'1/ 3, t4AAS,tAF,-, F -4 warms iu Pr crr, T'Yo POCKen or- fIIFD. _ A P 0" A -P F_'.L I I — 2 z gCJ FS,C.:0 v fZ El�' F(Ile ZOTS _ZZIL 112 11F*? SA)i DY z -S y Wwx zq 14i --I vvas Y 68 ASS 9iauEs Parent Material (geologic).... .. TLL ................................................. Depth to Bedrock: ,1A...._........ Depth to i5toUndwater: Standing Water in the Hole:$J.c..4jP$�' Weeping from Pit Face: �4r-lq7' Estimated Seasonal High Ground Water: FORM 11 - SOIL EVALUATOR FORM Page 3 + + + Determination for Seasonal High Water Table Method Used: , ❑ Depth observed standing in observation hole ................... inches ❑ Depth weeping from side of observation hole ................... inches E Depth to soil mott1 s2 1��2.� inches ❑ Ground water adjustment ... feet Index Well Number ................... Reading Date ......... Index well level .................. Adjustment factor,..... ..... Adjusted ground water level ........................................................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on -- RO' (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature FORN112 - PERCOLATION TEST COMMONWEALTH OF'_MASSACHUSETTS �-M-Si4 Al Wuvi5Z , Massiachusetts Percolation Test Date:... ..'..� ..'�(.ip . Time:......R.1-71-1, .......... Observa .'in Hole # _ Z 1 Depth of Perc 1 Start Pre-soak 1'3� 2 (3 End Pre-soak Time at '12" Time at 9" Time at 6" Time (9.,_6") Rate Min./Inch SHrlc. ZIAJ Site Passed Site Failed ❑ .......................................................................... Performed= By: LAS Witnessed By: Comments: ..... ..... ........ ............. ........... ........ .................................................... .... ............................................................................. ........... I 1%"') / :S .1"COY CECT/fY 777 T.YE T/TGE /.dSe*WO•r�4N0 719 7NEB04.V.r XV47 la LAC.4rE0 O.t/ MW 4ddr ofS 5AVO W ,4AIjO r/d4r?OAFS 6'64/FACA/ .WlrN rWe row1 O Ar -1,4 1,P o Q'E R ZOm/,v6 zeww.4mes Aw,rio4.t0/Os aem4c q ooc,,eom -smeETS , GOT elmeS. - .no7 e'r cewlFY rA,47- rife/,f O.4-eze/N6 Af Aldr G044MIP /,4/ T.YE FEA'-W0A& AePOp VKZWCO .4.PEW. SyaWA! 4/./ ieow q , COMNelAoVry /dWAI&.4 z6-,:vo9B 000 � G --- e 93 BLOT R1.4AI AIV O.P•9i�iV FO.P ' t�i9/YJi9/�C �ES/ G n/ I�EP.P/A1.gGf' E".v6.WEE.P/.1i6 SE.P/�/SES 66 f.Q.P,(� •ST.rEET LA150OPMC,. oOf,4X-14G�//SETTS O/8/O I SWlxj6 Timss. I ►� ��7' r=LE\/ All d >.15 -- rkt e- s.7: (A PP2ax) 231,36 CSDCi. C�2 . Pc B Zo.l 0O'f' S.T: Ill D �oK Z0I , 17 Zgo,g� D - g©)C Ll 1, 5' 31,2 ' ovT e p - 8OX Zoo, 71 EM TV, 5PC- H 10-0' 65,0 WZ-T-e. ` F-f�Z 2-7�,ey r� F -D TRIE�Je H �3 �tG, 3' f , I ' I � T., e T *+ s 278,60 FuD T-2 � I z o, 30 FuD TTL#Z 279, q(" E1�D T1Z*�� 273,efg N -LO -1 43,63z S, F �E�nc TAuJ,/ q6.(O - �9, 23' -Z - qz,oS. AS BUILT PLAN OF. DISPOSAL SYSTEM LOCATED IN KIoRTk ANDovER, MA. AS PREPARED FOR DAt hLL DPSiGQ � DE1G WC -,DATE: MAP-(f!f 13, 1997 SCALE: I `= 40 ' Lo -r �j Mll.L 2Q. MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, ,MASSACHUSETTS 01810 I Nov 5 ��n3 3� I (}j r���A�i1 O �'�,•I •1 Ilt '•S)'�{ !, II II \ P S rST�M' PUM�!I��^^�. hUDRMSYSTCm L ��. w, J \ � I U1IC/l� �'I �1 URE OF:SER%YI.CC ROUTInE Em ERCc.�; .';'."'.Y�J.�,C.Y.hI,U! I•Q ll.'. I' U 1. ,.T IV I U ! _ W WHITE CX'G.ESSIYPQS FLOODED ',l;;sgi lug cart'�Yq\r�R'_� p�.�, r, �•,',��'_ � --.. it M'PUMpC'OY r•U � i lel rr�Ts','> ,. L� .. '!(AL1 r x 0 0 A O N rn tz O C a 2t F r7 A � • eD l z fD 0 QIP 0z ~'n W d a ! > b T dod � y o fD ft O i ft Q � d a O CD a y � tap r CN O 1 O b i o a:� I CD U4 N O � 0 O I n � I , O C a rsrz 0 0z a d > b dod � y o � N Q a O pp Op :p Vl CN O 1 O i I A^ v e. > y ` IV C_ 3 FORM U- LOT RELEASE FORM 6 V C 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 or requirements. *******************''*********APPLICANT FILLS OUT THIS SECTION ********************* APPLICANT U WAtsOAJ__ PHONE LOCATION: Assessor's Map Number—L2—c— PARCEL_ SUBDIVISION LOT (S) STREET 1 ST. NUMBER TION COMMENTS TOWN PLANNER COMMENTS V1, FOOD COMMENTS OFFICIAL USE ONL AGENTS: rv, vR DATE APPROVED DATE REJECTED.............. ..... ... DATE APPROVED DATE REJECTED TH DATE APPROVED DATE REJECTED TH DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 11 7 I /.P Y. -19 LOT 4 43, 632, •F ; 254 9.002 'AC. CBA �Nl x. I 273-59 r or WORK -P. 7 3. 9C_ NOTES: 1. TOPOGRAP 2. PROPERTY -1 3. EXISTING C( SURVEY AN x 2- 281 IX 6' H/Gq E.)(,, 77NG LE FENCE 274 f X\28 19 s IN GRASS INc- If3 D - poy--J� EXIST' 2 24 Lti x 283 (1 B .11E, 79 TANK-L4-kl� V E R V2 A. IN!' i NIGHS C PAES.�2 29 L ON Co!" -PEtTAP\' 2Ktc IjLc i A.NL S A U LOPAh"! TON 141A L L 2-564 1 2a159 1/28019 27 .2f, E ED -3 E4 72. -.JZ 7 71 v a5 2 23 VE WA Y 28F4 x 280.71 r :'77 59 c'rrAiJ7 TOWN MA TOWN LO' D.E.P. Fil f x� - .�