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Home My WebLink AboutMiscellaneous - 261 BRIDGES LANE 4/30/2018T m 6 Cf) o �: 0 z p m 's $ .-f MAP # LOT # ict *--� J, PARCEL # STREET CONSTRUCTION APPRO HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE :t Z16—h 7 BY DESIGNER: w , - PLAN DATE :��A77 CONDITIONS W10ER SUPPLY: WELL PERMIT WELL TESTS:� PLUMBING SIGNOFF- COMMENTS: TOWN WELL DRILLER CHEMI BACTERIA I BACTERIA II DATE APPROVED DATE APPROVED DATE"APPROVED WIRING SIGNOFF FORM U APPROVAL: APPROVAL TO ISSUE NO DATE .31 ISSUED 7 1(9,7 BY 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:e//i5/V BY: ,� % A a SEPTIC SYSTEM INSTALLATION 0 0 IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT 4z) NO DWC PERMIT PAID? OES NO DWC PERMIT NO.- INSTALLER: BEGIN INSPECTION YES NO: EX,PAVATION INSPECTION: NEEDED: I. PASSED ZZI / 9 7 BY— tONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: 4� APPROVAL TO BACKFILL: DATE: BY FINAL GRADING APPROVAL: DATE Bi - FINAL CONSTRUCTION APPROVAL: I I DATE:—Z/7j4-7 -BY 1156 %,Aika iii P-%§. Ile — - - (z -) LA ki .AS BUILT PLAN OF 1 SUBSURFACE DI LOCATEDIN SPOSAL SYSTEM �J rvr�4 A w,c?cvz-e +-JLA$�. / L -or -zi,& AS PREPARED MR -B 0 71-o e-OLC'WIAL, VltLaC.:jE, C)FVp DATE: JULY al, 7 0 SCALE: 16 A-) MERRIMACK ENGINEERING SERVICES,—INC. PROFESSIONAL ENGINEERS 0 LAND'SURVEYORS 0 PLANNERIS " P ARK STREET ANDOVER, MASSACHUSETTS 01810 Or TEL (617)473-3553,373-5721 a FORM 11 - SOEL EVALUATOR FOR -NJ Page I No. Date ..... commonwealth of massaChusetts- z4vtnw Massachusetts sessment for On-vito Vouynan Peifonned By: ... ............. Witnessed By: ................ ............................ ............... .......................... ............. ............ ............................. ................................... .............. .............. L=11m Addreu or LAK, Owner'i N&��e v,,'11A7e. 4;?e Telephom /Vq7K.. AWa-ze� 44irL, C7 "PA:7 gz - 43 -z New Construction E9' Rd'pair' Offi6 Review Published Soil Survey Available:. No El Yes Year Published Iflew Publicati6 n Scale S oil Map Unit ..... Ce ..... Drainage' Class Sol"I Limitations . .................. ............. .. ......................... ............ Surficial Geologic Report Avallbble: No Yes Year Published . . .. ........ Publication Scale .............. Geologic Material (Map Unit) ......... ....... ........ .............. .. .......... .... . . Landform . .. ... ........ .. ... ... .... ... .............. . ................ .... ....................... ................. ..... ..... ..... ..... ......... Floo� Insurance Rate Map: Above 500 year flo od bdunclary N o Yes Within 500 year flood boundary No 9" Yes El Within 100 year flood boundary No Yes Wetland Area: National Wetland Inventory,Map (map unit) J: .... ............ . ................................................................................ Wetlands Conservancy Pro gram Map (Map unit).: ....................... ................................... .............. Current Wa'ter,Resource Conditions (USGS),: Month .......... Range: Above Normal Normal Below Normal Other References Reviewed: FOWNI 11 - SOEL EVALUATOR FORM Pa(,e 2 b On-site Review Deep Hole Number PP:1. Date: Time: Weather Yo "7 Location (identify on site plan) ........ ...... .... .......... * ...... .. .... *"* ....... ... Land Use .... V4 .... . .. -3.ro Surface Stones ... ... ..... I . ....................... Slope M Vegetation. . ..................... ... . ......... .. ....... ... ..... ........... - Landform010-1-01- itl- ...... .. . . ........................................... Position on landscape (sketch on the back) .. ...... . ............................ .............. . ...... .. . .................... ... ... Distances from: Open Water Body >.%,Cv' feet Drainage way feet Possible Wet Area 10 '4- feet Pro"perty Line feet Drinking Water Well >0w' feet Other . ......... .... .. DEEP OBSERVATION HOLE LOG Depth from Surface finches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Monling Other (Structure, Stones, Boulders, Consistencv, % Gravel! 1, 07- &.1 rst' 7, We ct A14�'Ss ACOWLALe k)-'7 6., - -yq Iq pww' Parent Material (geologic) . ....41, t L'. . .... ............................................... Depth to Bedrock: D�Pth to Groundwater: Standing Wa-ze.- in the Hole: Weeping from Pit Face: Estimated Seasonal Hign Ground Water: -? z LA FORM 11 - SOIL EVALUATOR FORM Page 2 On-site Review Deep Hole Number Date: Time: t'&% Pk" Weather 7 I ion (identify on site plan) Locat .......... ................. ** ...... Land Use .... V4-164V�e- �..-6k Slope M Surface Stones ............... Vegetation.f& ........ . .. ..... .......... ... . .......... .. ......... ..... ......... Landform........... . . . . .......... .... . ..... .. ....... ...... ........ ...................................... Position on landscape (sketch on the.back) . ............................ ............. . ........ .. . ................... Distances from: Open Water Body .>.JCV I feet Drainage wayLTW�L feet Possible Wet Area JL—,c�ott feet Pro'perty Line feet Drinking Water Well >to, feet Other . - ... .. .. DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistencv. % Grave')� 7, T YJ t -V-// 4,0- 57 Z" S -Y - '7Y 7, 5 1& .5 &12- IA� Parent Material (geologic) ....................................... Depth to Bedrock: Depth to Groundwater: Standing Wa-ze.- in the Hole: 7� ...... Weeping from Pit Face: Estimated Seasonal Hign Ground Water: -7q'/ FORM 11 - SOEL EVALUATOR FOPUNJ Page 3 Determination for Seasona Water Tab e Method Used: El Depth observed standing in observation hole ................. inches Dep -ik'eeping from side of observation hole ..... ............ inches Depth to soil mottles 5".-.Wir&hes, 7c,�!d El Ground ��ater adjustment fe" Pt Index Well Number .... ........ .. Reading Da�e .... ........ ...... Index well level .................. 'Adjustinent factor . ........ ... Adjusted'gr6unO water level ................. .................................. :Depth�of Naturaliv dccurring Pervious Material Does at least four feet of naturally occurring! pervious material exist in all areas observed throughout tho area proposed:folr the soil absorption zystem?* 4 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 thafthe above analysis was performed by me consistent with the req"Ljir'ed training, expertise and ex;.perience described in 310 CIVIR 15.017. Signaturojz� :te -7- Z-,� P I 4w FOMI 12 - PERCOLATION TEST COMMONWEALTH'OF MASSACHUSETTS Massachusetts Percolation Test Date- Time: .... .... Observation Hole: # Depth of Perc Z, Start Pre-soak End Pre-soak 7, Time at 12" Time at 9" Time at 6" ZA� Time (9"-6") Rate Min./Inch it Site Passed 2?/.,8ite Failed . .......................................... a Performed By: Witnessed By: Comrrients: I SEPTIC PLAN SUBMITTALS LOCATION: 0 NEW PLANS: S $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: — -�q �!a:) 6A 2 - DESIGN ENGINEER: When the submission is all in place, route to the Health Secretary FORM U - VERIFICATION FORM INSTRUCTIONS: This form*is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state lawl regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ra Phone - Ir L40CATION Assessor's Map Number &..o/b Parcel Subdivision -i " 01 Gr .1 Z14W _F_ Lot(s) Street f3 r i ACeu W -r 4!!:� — St. Number ZG ficial Use Only************************ RECdMMENDATIO OF' /AGENTS: Conservation Administrator ?Ye Comments C�11 Date Approved �2?1 77 Date Rejected lv�� Date Approved Town Planner Date Rejected Comments Food Inspector -Health Septi6 Inspector -Health Comments Date Approved Date Rejected Date Approved ,.541,1,7197 Date Rejected Public Works - sewer/water connections (-97 - driveway permit _` --I _�7 F�ire Department Received by Building Inspector Date b.alPAes L,6, 0 E, �r A"See-6), -rexn,�ry �-o * 174c, P4iLvv.A Pgtr. 7.v.,r7.nv-- f -pro. r1le Zar If$ SIWIVA" AIVAO 7Ae0fr1r,0CCS .,,Ylrll rwr-row4, a-4.,dopyVeat -zw.,,va zeavi.4news ,f4;AW1AW S&MA4CrX ,gZaW -v7,7!-,- 7- ZIMCS. " 40 .1044re-0 A/ rlllr A.-AAC-0.44 11,fZ.4.e,0 J�dAVAI 0// o, =/. o r , P/-, 4 1v //V "1414.-141 6,PLVWI^Lo, VIL-LA6e r7EV, OF .77 A,47 W JL41-1-t 3 81 "106591�46 5GQ,4149�1 I kk.,. SURVO Ln co A r w C.D LAJ LJ cn (44 Q'i L.J fn Li Ln co A APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:— 6 - _21 3 -_ q '7 LOCATION: Lc.r 4' -L— I CURRENT INSTALLER'S LICENSE# LICENSED INSTALLER: lAh'11A SIGNATURE: CHECK ONE: 104 31ZA11 19 ,TELEPHONE# /11'*�_ NEW CONSTRUCTION: IF, NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. .41 Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes No Approval Date: a Commonwealth of Massachusetss Massachusetts System Pumping Record � rTTWI 11 r IT r- -PY ". 0 Type: Emergency Routine Cesspool: KID s Date of Pumping: � W—VYY System Pumped By: Wind kw Enn-mmental, UC Contents transferred to: Contents Disposed at: eqs-�<7C(' Date: Pumper Signature: Condition of System/Other Comments Dep Approved Form - 12/07/95 Form 4 -- System Pumping Record Septic tank: W [::]Yes [M LLS.j Quantity Pumped: Gallons Permit #: 0 0 rpm C CN C-4 -P Ln 00 In CD V) Ln LJ V) c u z 0 �4 E > w w M5 rz Ln 0 Ln un ro rl z Ln 0 LU > rz LA _j <7 0 0 LL C) < 4-) L) 0 0 U 0 V) uj o LLJ Ln z c 1- 0 Ln 0 < 0 0 C) Z LL CO —0 LL) E (t u m E 0 ro 0 Ln �4 u < Or CQ rt E 0 Ln Ln 0 14 rd a) (1) Ln 'ZI q 4-) V) V) u C rz V) 0 rd :3 c: > 0 V) V) 0 .- 4� L) Ln r7 < VtORT#f 0 Ar#D CHUS Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 NO 171 TIVIV, .4 W- - I - - = V R -M DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant, (&� &::�� Test No, Site Location Reference Plans and Specs Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. ! . F 0 --.- Fee. (J() CFFA- I RMAN, BOA RD OF H EA LTH Site System Permit No. Town of North Andover, Massachusetts Form No. 3 ,AORT11 BOARD OF HEALTH 4o, OY 'JIM NMK.--, DISPOSAL WORKS CONSTRUCTION PERMIT S lop Applicant_,B/Z,/— '5 1,960 NAME ADDRESS TELEPHONE Site Location 2-e /-7-- g -�� --Oxe / -,�- - Permission is hereby granted to Construct k-lor Repair an Individual -Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CTI -AIRMAN, BOARD OF HEALTH Fee D.W.C. No. I 57A U) 0 C) 4-1 M 0 0 W 4--) r) NEW ENGLAND ENGINEERING SERVICES" INC lk \ A - <o -lo September 15, 2005 Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 0 1845 R E C E! VE, nt" I SEP 16 2005 TOWN OF Nk.�� tDO'VER HEALTH DE�Al, --�i----NT RE: TITLE V REPORT: RE: 261 Bridges Lane, North Andover, MA Dear Ms. Sawyer: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely, Ben4j�C. �Ofsg000d Certified Title 5 Inspector 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 I I of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Owner's Address: 261 Bridges Lane North Andover, MA 0 1845 Date of Inspection: 09/10/05 Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover, MA 0 1845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT RECEIVED SEP 16 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (3 10 CMR 15.000). The system: Inspector's Signature: X —Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority —Fails The system inspection shall submit a copy of this inspecition 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 fixture under the same or different conditions of use. 2 of 11. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: — Yes I have not found any information which indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: No 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 (YNND) in the for the following statements. If "not determined7 please explain. —___jle 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 imminen . System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: —_-Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s) are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced Obstruction is removed ND explain: 3 of 11. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 C. Further Evaluation is Required by the Board of Health: No Conditions exist which require ftulher 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 CNIR 15.303(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: — The system has a septic tank and (SAS) Soil Absorption System and the (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and the SAS is within 50 feet of a private water supply well. — The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of 11 . OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 D. System Criteria applicable to all systems: You must indicate "yes or No" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow — X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — X Any Portion of the SAS, cesspool or privy is below high ground water elevation. X _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply — X Any portion of a cesspool or privy is within a Zone I of a public well. X - Any portion of a cesspool or privy is within 50 feet of a private water supply well. X - Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO — (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 3 10 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: N/A 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 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 3 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 5 of 11. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 Check if the followine have been done. You must indicate "yes" or "no" as to each of the followina: Yes No X_ — Pumping information was provided by the owner, occupant, or Board of Health X - Were any of the system components pumped out in the previous two weeks-? - X Has the system received normal flows in the previous two week period ? X - Have large volumes of water been introduced to the system recently or as part of an inspection ? X_ — Were as built plans of the system obtained and examined? (If they were not available note as N/A) X - Was the facility or dwelling inspected for signs of sewage back up ? - X Was the site inspected for sign of break out? - X Were all system components, excluding the SAS, located on site? - X Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? X Was the fitcility owner ( and occupants if difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No X_ — Existing information. For example, a plan at the Board of Health. X Determined in the field (if any of the fidlure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (desigrl)__A_ Number of bedrooms (actual)L_A DESIGN flow based in 3 10 CUR 15.203 (for example: I 10 gpd x # of bedrooms� Number of current residents: 2 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): N/A Seasonal use: (yes or no): NO Water meter readings, if available (last 2 years usage (gpd): Sump Pump (yes or no): NO Last date of occupancy Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 3 10 CMR 15.203): gpd Basis of design flow (seats/persons/sqft, etc Grease trap present (yes or noh_. 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: 2000 12er old title 5 Was system pumped as part of the inspection (yes or no): NO If yes, volume pumped: ------gallons – How was quantity pumped determined?— Reason for pumping: 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) Tighttank Attached a copy of the DEP approval X Other (describe): 1000 gallon pgpR chamber Approximate age of all components, date installed (if known) and source of information: Built in 1988 Were sewage odors detected wen arriving at the site (yes or no): NO . 7 of 11 � OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 BUILDING SEWER (locate on site plan) Depth below grade: 48" Materials of construction:____�cast iron X 40 PVC—other (explainj___, Distance from private water supply well or suction line: N/A Comments (on condition ofjoints, venting, evidence of leakage, etc.): Pipe looks good in basement SEPTIC TANK:_(Iocate on site plan) Depth below grade: 36" Material of construction: X concrete metal—fiberglass-----polyethylene Other (expla If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): Dimensions: 1500 gailons —(attach a copy of certificate) Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle:— Ij- 1-0 Z)eeF -M Scum thickness: -0" 14 0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle - How were dimensions determined: Measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Sch 40 pvc tees ok. Inspection done with a mirror because the tank is so deep. Recommend installation of risers to within 6" of fmish grade on all openings. GREASE TRAP: N/A (locate on site plan) Depth below grade:. Materials of construction: concrete m,etal ----fiberglass olyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sludge 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. 8 of 11. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 TIGHT OR HOLDING TANK: N/A (tank must be pumped at time of inspection)(Iocate on site plan) Depth below grade: Materials of construction:____concrete—metal —fiberglass ---_polyethylene —___other (expla 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: W - . 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.): PUMP CHAMBER: YES (locate on sire plan) Pumps in working order (yes or no)___XES Alarms in working order (yes or no) YES Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Recommend installation of riser to grade to enable easy maintenance of pump. 9 of 11. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required If SAS not located explain why TYPE leaching pits number _____leaching chambers, number leaching galleries number leaching trenches, number in length X leaching fields, number, dimensions: I field 15 x 50 gpprox 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:—N/A (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: N/A (locate on site plan) Material of construction: Dimensions: Depth of solids Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Bridges Lane North Andover, MA 0 1845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 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. I 1--F /t — 1> 2 -]- Z 2-3 I -F z 2,D im CIV 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Bridges Lane North Andover, MA 01845 Owner's Name: Ian Davis Date of Inspection: 09/10/05 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6 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: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavator, installers - (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: System designed 4 feet above high ground water.