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Miscellaneous - 252 RALEIGH TAVERN LANE 4/30/2018 (2)
North Andover Board of Assessors Public Access % 4 "ORT" 1 wwno ✓♦ ,SSACMU`��t Click Seal To Retum Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 f rnwk rnnerb Recnrd C§krd Location: 252 RALEIGH TAVERN LANE Owner Name: LAI, XIONGWEN DANBING XIE Owner Address: 252 RALEIGH TAVERN 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: 2744 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 538,800 538,800 Building Value: 313,800 313,800 Land Value: 225,000 225,000 Market and Value: 225,000 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1465546&town=NandoverPubAcc 5/26/2009 TOWN OF NORTH ANDOVER t+ORT11 Office of COMMUNITY DEVELOPMENT AND SERVICES 3�o` °�eO "'60 HEALTH DEPARTMENT - p 1600 OSGOOD STREET•f Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public .Health Director 978.688.8476 —:FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATI ADDRESS: �7t MAP: �� LOT: INSTALLER:*,,z� %j'� DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS 611'A 1 TANK INSPECTION - DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑To ography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of k hole has 6" stone base ❑ Weep hole p ged ❑ 1500 gallon tan as been installed H-10 loading Mo lithic construction ❑ Water tightness of to has been achieved (Visual or Vacuum Test Water held for 24hrs) ❑ Inlet tee installed, centere nder access port ❑ Outlet tee (gas baffle or efflu t filter) installed, centered under access port ❑ 24" inch cover to within 6" of final ade installed over one access port, must be over out of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER BORTH . ��°� �' o...O Office of COMMUNITY DEVELOPMENT AND SERVICES °``t��� . , ` ,'e HEALTH DEPARTMENT - p 1600 OSGOOD STREET; Building 2-36 " s NORTH ANDOVER, MASSACHUSETTS 01845 �'"ss�CHus��`h Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public .Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 . is D -BOX TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES oro4't"o '" °4,°gym HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 �. NORTH ANDOVER, MASSACHUSETTS 01845 SS US Sawyer, REHS/RS 978.688.9540 — Phone Director 978.688.8476 — FAX Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated .as per plan ❑ itle 5 sand installed, if specified on plan ❑ 3 -1 Y2" double washed stone installed ❑ 1/8- 2" (peastone) double washed stone installed ❑ Latera installed and ends connected to header ❑ Laterals ented if impervious material above ❑ Orifices @ & 7 o'clock positions ❑ Gravel -less posal systems: type, number and location as per Ian ❑ Elevations of lat als installed as on approved plan ❑ 40 Mil HDPE barri installed ❑ Retaining wall (boul r/ concrete /timber/ block) ❑ Final cover as per plan\ Comments: Wastewater System Documentation — Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER°Rrk Office of COMMUNITY DEVELOPMENT AND SERVICES s��o'°°�°ate HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �9SSACHUSY��h Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public .Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION Comments: CONTROL PANEL Comments: -- inch manifold laterals installed with end sweeps size: material: Squirt test ft in height Equal distribution to all laterals orifice size inch as per plan ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Wastewater System Documentation — Feb 2006 Page 4 of 6 '1 TOWN OF NORTH ANDOVER FORTH H Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 ^� Neo «n..n.... `. NORTH ANDOVER, MASSACHUSETTS 01845 "Ss.'C USE�`� Susan Y Sawyer, REHS/RS 978.688.9540 - Phone Public Health Director 978.688.8476— FAX . CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ❑ Wetlands bordering surface water supply or trib. (in Watershed) Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20: -- ❑ inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER aaeTk Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845"SSACHUa�s`y Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 NORTFi 0t O� stereo ,s,O 3? F 6 OL co co « lea SSAC HUs���y PUBLIC HEALTH DEPARTMENT Community Development Division (-'�F127I FICA�I'E OAF C091�L�LIANCYE As of: ,dune 1, 2009 This is to cert that the individual su6surface disposal system received a SA7IST,4C`70RT 15VSPEC 70Y of the: 12epCacement of the Distri6ution Box By: 7ocld'Bateson At: 2S2 4;�oki ►h tavern Gane Map -106. C; Parcel- 108 North Andover, MA 01845 ,The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. S _an"�Y. Sawyer lMfic Yfealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com ttORT, q O �,,%.te ,s* ti0 9 coc.oinew.cw . 1' PUBLIC HEALTH DEPARTMENT Community Development Division �E1271�'ICA7E OAF CO�VI�l'LIA.�VCYE As of: dune 1, 2009 riis is to cert that the individual subsurface disposal system received a S,4g7S FAC70RT 1YSTEM0X of the: RepCacement of the Oistri6ution Box By: Todd Bateson At: 252 q;Z0Ceigh tavern Gane 911 ap -106.0; Parcel -108 North Andover, JKA 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the system wilt function satisfactorily. XS ,an,� Sawyer ft 6Cic Health Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. '" VAI Commonwealth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary E 252 Raleigh Tavern Lane Property Address Evan Lai Owner's Name North Andover City/Town MA 01845 State Zip Code RECEIVED 15 2009 TOWN OF NORTH ANDOVER 6/1/2009 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. • / � , A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Ma 01810 State Zip Code SI15 License Number 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: E Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/1/2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 2110:7 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner's Name North Andover MA 01845 6/1/2009 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from Board of Health, pumped septic tank & install new d -box with risers, inspection from Board of Health, septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. UQ RM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner's Name North Andover Citylrown MA 01845 State Zip Code 5/23/2009 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Ma State S115 License Number 01810 Zip Code `ev10y lam' I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/23/2009 Inspedlor4i SIgnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 0 Owner information is required for every page. t5ins • 09/08 Commohwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner's Name North Andover MA 01845 5/23/2009 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes","no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): Title 5 Official Inspection form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner's Name North Andover Citylrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 5/23/2009 State Zip Code Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 MAN Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owners Name North Andover MA 01845 5/23/2009 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D -Box replacement D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner Owner's Name information is required for North Andover MA 01845 5/23/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner's Name North Andover MA 01845 5/23/2009 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ` 252 Raleigh Tavern Lane Owner information is required for every page. Property Address Evan Lai Owner's Name North Andover Citylrown D. System Information Description: MA 01845 5/23/2009 State Zip Code Date of Inspection Water meter readings, if available: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( y 9 (gpd))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: March 3,2009Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 252 Raleigh Tavern Lane Owner information is required for every page. Property Address Evan Lai Owner's Name North Andover MA 01845 5/23/2009 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2003, owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavem Lane Property Address Evan Lai Owner Owner's Name information is required for North Andover MA 01845 5/23/2009 every page. Citylrown D. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 27 old, 9/3/1981, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 5 feet Material of construction: ❑ Yes ® No ❑ cast iron ❑ 40 PVC ❑ other (ex Iain)• unknown, finished cellar P Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 4 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 3" ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 252 Raleigh Tavern Lane Property Address Evan Lai Owner information is required for every page. t5ins • 09/08 Owner's Name North Andover MA 01845 5/23/2009 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 24" 5„ 8" 1611 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.): Inlet & center cover under deck. Outlet tee ok. Depth of liquid at invert, no evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , •�''p 252 Raleigh Tavern Lane Property Address Evan Lai Owner Owner's Name information is required for North Andover MA 01845 5/23/2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 252 Raleigh Tavern Lane Property Address Evan Lai Owner Owner's Name information is required for North Andover every page. City[Town State Zip Code D. System Information (cont.) RAA AAAA/` 5/23/2009 Date of Inspection 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 evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. Evidence of leakage. D -box needs to be replaced. Evidence of Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner Owner's Name information is required for North Andover MA 01845 5/23/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface.Camera inside of pits thru outlets in d -box, no water to inverts Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner's Name North Andover MA 01845 5/23/2009 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 09/08 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner Owners Name information is required for North Andover MA 01845 5/2312009 everypage. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below drawing attached separately �%Jv t j) R;-Va /1 -AV — .y 11-611 'of rt t5me • 09108 Title 5 Official lrispecUm Form; Subsurface Sawsp Dmposel System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 252 Raleigh Tavern Lane Property Address Evan Lai Owner information is required for every page. Owners Name North Andover MA 01845 5/23/2009 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4' below pitsfeet Please indicate all methods used to determine the high ground water elevation: FS 0 Obtained from system design plans on record Ifhekddt f I d' 5/24/1980 c c e, a e o esign pan revlewe . Date 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 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 252 Raleigh Tavern Lane Property Address Evan Lai Owner Owner's Name information is required for North Andover MA 01845 5/23/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 3113/200910:19:41 AM by Lisa Evans Town of North Andover Tax Map # 210-106.C-0108-0000.0 Page 7 Parcel Id 17741 • 252 RALEIGH TAVERN LANE LAI, XIONGWEN & XIE, DANBING 252 RALEIGH TAVERN LANE N. ANDOVER, MA 01845 _ Class 101 Single Family Property Type 1 Residential Size Total 1.03 Acres FY 2009 UB Mailing Index Name/Address ' Type Loan Number Activellnact. From Until LAI, XIONGWEN & XIE, DANBING Payor 252 RALEIGH TAVERN LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14147.0 - 252 RALEIGH TAVERN LANE Last Billing Date 3/5/2009 2100131 02 Cycle 02 Active UB Services Maint. Account No. 2100131 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 215.91 /1 UB Meter Maintenance Account No. 2100131 Serial No Status Location Brand Type Size YTD Cons 0002912854 a Active ENC RT w Water 0.63 0.63 161 Date Reading Code Consumption Posted Date Variance 2/4/2009 3707 m Manual estimate 50 3/16/2009 -8% MSG 11/3/2008 3657 a Actual 55 12110/2008 -4% 8/1/2008 3602 a Actual 56 9/12/2008 60% 5/1/2008 3546 a Actual 33 6/18/2008 -25% 2/4/2008 3513 a Actual 48 3/14/2008 -1% 11/1/2007 3465 a Actual 47 1/15/2008 4% 8/1/2007 3418 a Actual 48 9/14/2007 14% 5/3/2007 3370 a Actual 30 6/22/2007 54% 2/28/2007 3340 m Manual estimate 36 3/23/2007 -38% 11/2/2006 3304 a Actual 36 12122/2006 -40% 8/21/2006 3268 aActual 89 9/13/2006 101% 5/4/2006 3179 a Actual 37 6/20/2006 39% 2/2/2006 3142 a Actual 27 3/13/2006 -36% 11/2/2005 3115 aActual 38 12/14/2005 -10% 8/11/2005 3077 aActual 48 9/12/2005 86% 5/9/2005 3029 a Actual 23 6/8/2005 7% 2/14/2005 3006 a Actual 23 3/15/2005 -19% 11/16/2004 2983 a Actual 31 12/172004 -19% 8/10/2004 2952 a Actual 33 9/20/2004 29% 5/17/2004 2919 a Actual 27 6/14/2004 -25% 2/17/2004 2892 a Actual 41 4/16/2004 0% 11/6/2003 2851 n New Meter 0 11/6/2003 0% _ O` NORTH ,� • E F 9 r . r Town of North Andover HEALTH DEPARTMENT SACHUSt A CHECK #: `/ D TE: 6 ©9 i i LOCATION: i H/O NAME:�f'�� CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ s. ❑ Body Art Establishment i; $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title,5Inspector 0","" 5 Report $ $ a ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer t AORTk Commonwealth of Massachusetts Map -Block -Lot °�•�`° 'a 106.0-0108- Board of Health Permit No BHP -2009-0533 North Andover _______________________ ' P.I. y �••ra .''".t` FEE CwuStS F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd-B-ateson --------------------------------------------------------------------------------------------------- to (Repair -D -BOX) an Individual Sewage Disposal System. at No 252 RALEIGH TAVERN LANE as shown on the application for Disposal Works Construction Permit No. BHP -2009-053 Dated May 22, 2009 ------------------------ ----------------------------- Issued On: May -22-2009 L o� Health a �s® w4Rt,,� Commonwealth of Massachusetts Map -Block -Lot ,,,�� VI 8 �a 106.C- 0108 - Board of Health North Andover Certificate of Compliance \$SAIL,. THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair -D -BOX) by Todd Bateson --------------------------------------------------------------------------------------------------------------------------------------- Installer at No252 RALEIGH TAVERN LANE ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -HP --- -2009-053 Dated May -22,-2009 --B-------------------- ---- -------- ---------------------------------------- Printed On: May -22-2009 Board of Health ---------- - - - - - ' 4"i d Town of North Andover HEALTH DEPARTMENT CHU CHECK #: DATE:, LOCATION: f' CONTRACTOR NAME: Type of Permit or License: (Check box)�- ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) % $ r + ❑ Septic Disposal Works Installers (DWI) $ 0 Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ 5 ,14ealth A& &t Initials White - Applicant Yellow Health Pink - Treasurer M a N �4 M co LO qzs w J J O a ti .a rM ti rM rM ti J o- ti O rM -0 -0 �•/ O Lro ME I Ln O O Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _ 1� Application for Septic Disposal Svstem Construction Permit - TOWN OF RTH ANDOVE Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair -or replace an existing on-site sewage disposal system* 2 -6 -pair or replace an existing system component — What? A. Facility Information 11 _ Address or Lot # City/Town s- a✓ e 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump g-Glnity (choose one) ;-a-G� TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component L'I -- .la e ***I pump system, attach copy of electrical permit to application*** Conventional System (pipe and stone system) cap�YWy��SJ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information '7— Name Address (if different from /above) Q City/Town 3. Installer Information j 11-74, ::�, / S-yS State Zip Code 0/7 Telephone Number Name Name o QN EMT C=ALL v^, •,a., Address / T— - �� ���� o Andov� ®I 8 10 City/Town State Zip Code Telephone Number (Cell Phone # if possible ple se) a. Designer Information Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 f MORTN, Application for Septic Disposal System �Xonstruction Permit —TOWN OF ORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility. Information continued 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement -JU—G/ TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issue this Board of Health. Name Date Applicatio A roved By: (Board of Health Representative) �-?10-d� Nam Date plication Disapproved for the following reasons: For Office Use Only: I Fee Attached. Yes ✓ No 2. Project Manager Obligation Form Attached. Yes .I/ No 3. Pump S sv to If so, Attach copy of Electrical Permit Yes No 4. Foundation As -Bur -I (new construction ronly): Yes_ No (Same scale as roved plan) 5. Floor Plans? (new construe% only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) i Relative to the application of (Installer's name) Dated O — �ZIodays ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) ngtna ate (Last revised date) 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 manager, 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 necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may_result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (15) inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection. for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@townofnorthandover.co from the engineer must. be submitted to the Board of Health, after which installer calls, for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done 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 ofHealth 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 api2roved plans No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) ame —Print) e —Signed) 6 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 n CERTIFICATION Property Address: -2 S2 /� /9 L;',EVF_/e.t- C -9— F_ /7�y1%ot/ER�/ SS UI$�fS Owner's Name: �u C �`ra /n Owner's Address: i GGit 7-15v,, 1V 4v9 -v6 TOvVN OF NORTH AND01" -�i/ //U, /l-vOGVL r�95S 0 / 9, q-6— BOARD OF HULTH Date of Inspection: — p / t hJAY 18 2Qn1 Name of Inspector: (please print) EOw,-JL/l :0 Company Name: ti% Mailing Address: Zo c_.4_E EY L- S.9-- v.y 036i/ Telephone Number: /- CERTIFICATION — 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 /--"—p a s s e s _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector'Ls Signature: _ �I ,�. o 1/oz� Date: — °1— C> 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 ALTHOUGH THIS REPORT MAY BE DEEMED RELIABLE, NO WARRANTIES OR GUARANTIES ARE EXPRESSED OR IMPLIED. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: FQH 7_4v,z2N, jog -.,,r Owner: L i Iv,019 C Date of Inspection: �6 — c% —o / Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: 4z 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 structural]y 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 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2S2— 1�4 L I'a QH tAvc—:X1z1 N 0. 4,-120i/4;;:A ; �yts O Owner: L,)X4%1,Y C1'rnMjti0 Date of Inspection: — 9 — C9 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 NNill 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 eater supply The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply "ell _ 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 supple well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacte-ia 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 I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z 5-2 lg1�1/ZEGH TAvc e v L19-yE 4-0, clqlils- Owner: LDom, eD Date of Inspection: �4 — �J— 0 / D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool !� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t/ Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool /Liquid 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 SAS, cesspool or privy is below high ground water elevation. (/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. 1/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma Wo (Yes,mo) 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 o\\ner 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 (IInterim Wellhead Protection Area — I WPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered ,,yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2 S2/�BLi�FGfi %Ar/E/'� L -,9-11E A/ o , 14r'Dou c_,2 Owner: C;'mi-i/-,v0 Date of Inspection: q — 0f — 0 1 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No t� 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 pan of this inspection ? _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up _ Was the site inspected for signs of break out ? _ Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ',) 11e size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. Determined in the field (if an), of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (3 10 CMR 15.302(3)(b)] 5 Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ 252. 9/9&/'CQy T-"!911eR2 /1/0, h�w.0ovc..Q r�.sss. OIS�� Owner: 4-- t N P,0' C, m n1-1vd Date of Inspection �L- ?-0/ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _3_ Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder (ym or no): Al 0 Is laundry on a separate sewage system (yes or no): (if yes separate inspection required) Laundry system inspected (yes or -p,.&):' Seasonal use: (y4� or no):/y0 Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): &6 Last date of occupancy: S- COMMERCIAL/INDUSTRIAL Type of establishment: Design now (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: Was system pumped as pan of the inspection (Tesor no): {VO 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) _ 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 ase of all components, date installed (if known) and source of information: 20 /51 S fIu, T '0 Were sewage odors detected when arriving at the site (yes or no): Page 7 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 S2 j1/'VE A, LyvvF_ 410, �,VDay �R , :g1 /3SS O / SYS' Owner: 5140wj C"'01 "l",vo Date of Inspection: Z7' — 9 _ C/ BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition ofjoints, venting, evidence of leakage, etc.): SEPTIC TANK:(locate on site plan) Depth below grade: B �i Material of construction: Yoncrete _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: , S0 6-',9 &1- o rvS Sludge depth: & ' Distance from top ofjudge to bottom of outlet tee or baffle: cg 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: Ho\s %kere dimensions determined: 7-/1;1PF,0 Comments (on pumping, recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 bottorn of outlet tee or baffle.- Date affle: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 I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 S2 R19 LJ c o H T.gve,.Qry Leve /uo. 9wooyFR f /1-7 55 , 0 /6y5� Owner: L/ i07 'm a.4 Date of Inspection: '/-- q -0 TIGHT or HOLDING TANK: (tank must be pumped at time of inspect ion)(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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0L11C Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover. anv evidence of leakage into or out of box, etc.): /V 0 1/ e— PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms,in -vorking order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 S-2— /Vo, 2/Vo, "4W'a0Ve'< ' i29i�SS, 016 Owner: cl,I ,7;wo Date of Inspection: c.f — G — o / SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why:. Ty'pee !/ leaching pits. number: 2 leaching chambers, number: leaching galleries, number: leaching trenches, number, length.- leaching ength: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.): CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert. Depth of solids layer: Depth of scum la\er. 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 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 S 2 /Q ,,3z L l'F—a f T,9c/Lk"I L-'9'v— ivo. 4PVV0V1 ✓1 .9gs, dl0'sS Owner: <.,14/&! -1Y6 Date of Inspection: — 9— 0 ! 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. 10 Page 1 I of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 5-2- 1��6 1,5c -ll r'/�v �v y q vF yv,Rrvoo��R�m,9�S. o�8�r Owner: Llivojt�' C 11w n, -,w,) Date of Inspection: �Y( — q— C/ SITE EXAM t e wat cell Shallow wells Estimated depth to ground water 6 feet Please indicate (check) all methods used to determine the high ground water elevation: ( Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water el , 4s S' 1 D '3i Ilk 1 i ql l F�aI��C G�.rrt�.�a �i id►S3C�iLwTE'S C P�, C�1 N��i.�5► � J��C.brt f't''EGT C3 . 4 0 TO: K'6- Aw Doge e E�o a 1-p or HeA --rH FROM: 1:�P-A WL C. (-=>GL S � NORTH ANDOVER, ?SASS. 1981 BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have inspected the construction materials of said disposal system at l_D T lr_- P -Au i&, -1 T&. 6e-kl Site Location North Andover, Mass. The grades and construction materials are as specified in my plans and specifications dated /�P�1(.. Z4 1981 and `���'T 3 19 _. n � n __ Reg. Prof. Engineer/Reg. Sanitarian 4>- } Arm ES Li UL 'T P.M m �c t4 4„ A S SGxG lA'"t e's Mm Arm ES Li UL 'T P.M m �c t4 4„ A S SGxG lA'"t e's Mm Board ofHeal th North Air Mass. J Y M J. SEPTIC S'ai ZaiS3TAg.LATICK Cwt;$ LIST 77' t L0Titlf�/( AVAT`I ON OK FAi I; - 1. Distance To: a. Wetlands b. Drains c. Well Ile 2. Water Line Location 3• No PVC -Pipe 4. septic Tank --- a. -Tees -_Length & To Clean Out Covers. _ - b. Cement Pipe to Tank - On Both Sides of Tank _ 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow b. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped 'Eads d. Clean Double Washed Stone 7;b. Lch Pits Dimeu no S Depth ash Pads TeesCement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9• Final grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table Board of , Hcalth North Andowrjr.ry-is V 6JI)SWR i ACE DISPOSAL 3 MIM CHECK LIST LOT U APPROVED DATE DISAPPROVED DATE Provided: Reasons: Title V "AIL 0Z Reg 2.5 The submitted plan must &%ow, as a minimum*. a) the lot to be served-area.,dimensions lot #$abutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations shouring requirvd leaching area (e) location and dimensions of system -including reserve area f) ey—I sting and proposed contours (g) location any tet areas vithin 1001 of sewage disposal system or disclaimer -check vetlands mapping mirr-ca and sub:.wface drains vi.tii n 1.00+ of supe disposal. Ty6t,�rl or rxv _ t e ru-,;=,its �Ai-TO.n U)01 of cevnge disposal. (j) lmtwa ccwy--cs of t r LnTrl,y i1thi n 2001 of sewage disposal or 6,UicI&Disr M location of Lkuy- propose7d v-,,11 to soap lot -1000 from leaehing facility (1) location Of 1.404 .1ines on propy ,-qty-101 from leaching facility (m) location of b ichmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution boat inlets and outlets, distribution field piping and Other elevations (r) Maximum ground water elevation in area se%rage disposal system (s) plan mst be prepamd by a Frofessierwl EagImeer or other professional authorized by law to prepare such plans Reg 6 Se •tic Tis (a) capacities -150% of flow, mter table, tees, depth of tees, access, pining (b) cleanout (c) 10' from collar wall. or inground s�.dmming pool (d) z51 frog: subsurface drams Reg 10.2 Distribution Boxes (a) slope ter than 0.08 Reg 10.4�(b) suV i }y ' FAIL OK Leachi!n!gg Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-wInimum 500 sq ft 11.4 b) spacing 11.10 c) surface drainage 2% 11.11 [d) cover material e) ' x2 t x4" splash pad f) tee at elbow __ g) no bends in pipe from d -box to pipe Leaching Fields Reg 15.1 a) no greatMian 20 minutes/inch b area-rdnim= 900 sq ft 15.4 I'e) construction of field 15.8 d) surface drainage 2 % 3.7 201 from cellar vmll or inm:, nd s4Amming pool Leaching r.VFA=hes Reg 14,1 14.3 14.4 34.6 X4.7 14.10 a) McMtlons o eaching area-rdn 500 sq ft b) spacing -4 ft mdn 6 ft with reserve betheen c) di mvi.on.s const mction e) store f) surface drainage 2% Do- i?1 Slope a) s ope y xto be shovm) b) y/x % 150 = (to be shown) --Id) S Reg 9.1 a) approval. 9.6 b) stand-by power i Board of Re:Ith T -.-- Nortl1 �ndovor,K ss SUBMIFACE DISPOSAL DESIGN CHFP'K LIST LOT` APPROVED DATE DISAPPROVED DATE Provided: Reasonss A14 Title P F'iTL 0"4r �14r Reg 2.5 fiThe submitted plan must sho:r as a ri xdj=: a) the lot to be served-area,dir.ensions lot ##,ab-atters b location mnd log deep observation hales-distance to ties C location and ruts percolation tests-distance to ties Ld design calculations & calculations ahog rireA leaching area (@) location: and dimensions of item-including reser-a area existing and proposed contours g) location any trot areas Idti-An 1.001 of sewage disposal system or ,�- disclairzr-check vatlands mapping (h) Mace and scbsurfaco drains within. 1.00t of sel;2ge disposal system or disclaimer (i) locations any drainxage easen -ats within 1001 of €fuze di.bposal system or eAsciair"ar-Pl,-a n ng Board .files (J) knog-.t sources of v--tar simply w3 vbin 2001 of spm.-Wige disposal - system or disclaimer (k)-location of Proposed v-ell to sem lot-1001 from leaching facility location of vater lines on pr operty.-10 from leaching facility location of benchmark ✓ (� u- drivei�ys /(o) garbage disposals (4) profile of systcm,elcwbti.onB of basement, plumb, pipe, s�ptjc tank, 6is Gribution box inlets and out-lots, distribution field piping and Utter elevations j M 0.1>dwam ground iater elEvlation in area se- a dispoiaf system v' (s) plan must, be prepared by a Professional or other profes -ional authorized by law to propare such plans RGg 6 �, / Se tic Tanks (a) c4?pacit os-150% of flow., e=ater table, tees, depth of tees, ' access, pu Ping (b) cl WMout (c) 3A1 from cellar i,--U or ingroLmd mAmdng pool _ v- (d) 251 from subsurface drams Reg 10.2 Distribution Daxe:s (a) slope greater th.-m 0.08 4 Reg 10.1 / b) { -i 1� � S bsurfae'e D,-^ign eh(ck TA st _ e 2 _ FML OK Leaching Pits y ? Reg 11.2 1.1.4 �'� Leaching pits are preferred xhere the installation is possible a) calculations of leaching area -a nim m 50o sq ft ac gib' 11.10 11.11 c `' ;d -I surface drainage 2% cover material v �6) 2lx2fx4a splash pad toe at elbow �. t g) no bids in pipe from d -box to pipe Reg 15.1 a) Leaching FleVis n3 gro no Man 20 mutes/inch { r 15.4 15.8 3.7 Reg 1.4,1 14.3 14.4 3J,,.6 1x:.7 3E�.10 b) area -minima 900 sq ft c) construcIton of field d) face" drainage 2 % ®) 20 f m cellar imll or ingrowid sdm ng pal Leaching, caches -- a) cq c oras o ' eaching area-rdn 500 sq ft b) spacing -4 ft ran 6 ft with reserve bet% -,ea c) dirx-jAons d) etas action 10) stone f) surface drainage 2% a) b) D:null. Slop e sTope v7x --oto be sIho1�:n y/x X 150 = (to be ;ho,., / s Reg 9.1a) 9.6 b) -MS�. approval stxid-by power . s~ TOWN OF SYSTEM PUMPING RECORD ,)UI 3 0 2003 DATE: A3 A SYSTEM OWNER & ADDRESS L�- �� ITak f SYSTEM LOCATION (example: left front of house) M)f j l \ �� � CLI O DATE OF PUMPING: QUANTITY PUMPED : CESSPOOL: NO YES EPTIC TANK: NO NATURE OF SERVICE: ROUTINE j EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER 14-4�1/ GALLONS YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: 14- L Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided here. BE local Board of Health to determine the form they use. The System P the local Board of Health or other approving authority. RECEIVED SUN - g 2009 Ib'4lis-fl1m,-check with your Record must be submitted to A. Facility Information 1. System Location: Left fro le rea left sid of Nous . Right front, right rear, right side of house. Address City/Town 2. System Owner: Name Address (if different from loca City/Town (N r\j , VINT State Zip Code Stated � Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: Cesspool(s) eptic Tank Ll Tight Tank Other (describe): 4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? Yes [j No 5. Condition off Ue ` )(� ' 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location ere contents were disposed: L.S.D Lowell Waste Water a F 5821 Vehicle License Number of I-Iduthr Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner & Address: Laura Nardone 252 Raliegh Tavern Ln North Andover, MA 01845 Location of system: Rear Date of Pumping: May 22, 2012 Type of system: Septic Tank Gallons Pumped: 1250 gallons System pumped by: Service Pumping & Drain Co., Inc. S Hallberg Park North Reading, Ma License #: BHP -2011-0413,0412,0411,0410,0409,0408 TOWN OF R HEALTH Contents transferred to: Greater Lawrence Sanitary District Date: May 25, 2012 Pumping Technician: CH This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes