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MO FT a �`
an\
21ProDertv Record Card
xation: 261 CARLTON LANE
wner Name: BRYANT, JAMES S, III
MARY ELIZABETH BRYANT
wner Address: 261 CARLTON LANE
City: NORTH ANDOVER State: MA ZLp.j 01845
eighborhood: 7 - 7 Land Area: 1.05 acres
se Code: 101-SNGL-FAM-RES Total Finished Area: 2960 sqft
ASSESSMENTS
CURRENTYEAR
PREVIOUS YEAR
Total Value:
613,500
633,900
Building Value:
388,400
408,800
Land Value:
225,100
225,100
Market Land Value:
225,100
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkId=1465843&town--NandoverPubAcc 8/14/2009
\4,10
0
of
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
%-' A -j A- -I--#
r'FRT11F1C4rr1F OE CWIPLIAACE
As of-.
,4ugust 17, 2009
This is to certify that the inSividualsu6sutface d4osaf system receiveda
SMUTACTORTIM(PEWONof the:
ft&cewnt of Outfet Tee in Septic TankOnfy
By
ToddBateson
261 Catfton Lane
Wap — 107-,g.,- (Parrel-212
NorthAndover, 911A 01845
The Issuance of this certificate shaff not 6e construed as a guarantee that the system wiff
function satiy�tctorffy.
T
ft6lt'c 9feaftK(Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 fox 978.688.8476 Web www.townofnorthandover.com
RTh
Town of North Andover
HEALTH DEPARTMENT
'A U
CHECK#: -117J& PATE:
LOCATION:
H/O NAME:
NAME:
Type
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type:
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
13
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$-
0
Well Construction
$
SEP77C Systems:
0
Septic - Soil Testing
$
0 Septic -,Design Approval
--a �Stic
$
101-
Disposal Works Construction (DWQ
$
0
Septic Disposal Works Installers (DW[)
$-
0
Title 5 Inspector
$
0
Title 5 Report
$
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
V40"T04 Commonwealth of Massachusetts Map -Block -Lot
107.AO212
-----------------------
Board of Health Permit No
-4PP
BHP -2009-0651
North Andover -----------------------
PA.
FEE
F.I. $125.00
----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted -Todd-B-ateson -----------------------------------------------------------------------------------------
to (Repair -OUTLET TEE ONLY) an Individual Sewage Disposal System.
atNo -26-1-CARLTON-LANE
as shown on the application for Disposal Works Construction Permit No. BHP -2009-065 Dated August 14,2009
------------------------ ------------------------------
--------- ---- -------- -
Issued -On: - Aug -I - 4 - - - 200 - 9 ------------------------------------------------- — ------------- H&M - -----
N Commonwealth of Massachusetts Map -Block -Lot
107.AO212
-----------------------
Board of Health
. qvvuw North Andover
CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFYThat the Individual Sewage Disposal System (Repair -OUTLET TEE ONLY)
by... Todd -Bateson --------------------------------------------------------------------------------------------------------------------------------------
Installer
atNo-26-1-CARLTON-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. -BH-P-2009--065- - Dated --- AuguA_14,2009 ....
--------------------------------------------------------
Printed-On:--Aug--14--2009 ---- ------------------------------------------- Board of Health
ts
Applill:Mion for Septic Disposal System
TODA'f S DATE
Construction Permit -TOWN OF
�qORTH ANDOVER, MA 01845 $ 250.00 —flall-Revairr
Compo�en�t
Important: ADMication is herebv made for a i)ermit to:
When filling out Construct a new on-site sewage disposal system*
forms on the
computer, use Repair or replace an existing on-site sewage disposal system*
only the tab key - - —_�C--
to move your &Rfi-p--a-ir or replace an existing system component - What?o uA-�� -w�,
cursor - do not
use the return A. Facility Information
key.
Address or Lot # RECEIVLU
cityrrown P 0 AUG 13 If D
2.- -TYPE OF WTIC SYSTEW: TOWN OF N DRTH A OV R
El Pump 3travity (choose one) L__.tEALTH VEPA 2009
***ff system, attach copy of electrical permit to application"* ld,� vz__�
TOWN OF ORT -1 ANDMER
0�onventlonal System (pipe and stone system) HEALTH DEPARTMENT
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) (At tach Draft Maintenance Agreement)
El Pressure Dosed (D -Box Present) S.A.S.
2. Owner Infonnation
Name
Address (if different from above)
Cityrrown
3. Installer Information
__�_o �_,A P -S Ct�
Name �)_�
Address
Cityrrown
4. Desig-ner Information
Name
Address
Cityrrown
State Zip Code
S-C&G S-3 -0 '_7 P7 L)
Telephone Number
Name of Company
State Zip Code
(::7( rl a, — 3 110 -,:s
Telephone Number (Cell Phone # ffpossible please)
Name of Company
state
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page I of 2
M
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: 2re-sidential Dwelling or E]Commercial
B. Agreement
Y -ti -6 1�
TODAY'S DATE
,_$-2SD-.D0--, Full Repair
$125.00 - �omponent
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 Ando Tr, and not to place the system in operation until a Certificate of Compliance has
this Board of Health.
been is
S
Name Date
atio Appro�ve a Health Pipi6senta
r
/Ca mf Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached?
2 Project Manager Obligation Form Attached;
3. Pump &-stem? If so, Attach coQv of Elecaicaj Permit
4. Foundation As -Built? (new construction ronly):
(Same scale as approvedplan)
9. Floor Plans? (new construction only).
Yes,111 No
yes No
Y �s
eSJ No
Ye No
Ye,!�__ t No
Application for Disposal System Construction Permit - Page 2 of 2
4.
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As�the North Andover licensed installer for the construction for the septic system for the property at:
fD'C"Z� I
(Address of septic system)
Relative to the application of oc��
(Installer's name)
Dated
(I oday-s date)
For plans by
And dated
With revisions dated
I understand the following obligations for management of this project:
(Engineer)
(Unginal date)
(Last revised date)
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans piio—r to
performing any work on a site. I must have the approved 121ans 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 Lequesting an inspection, without co=letion of the items in accordance
with Title 5 and the Board of Health kegLiktlons tna-y result in a $50.00 fine being levied agaigst me and/o
my commy.
a. Bottom of Bed — Generally, this is the first (1'� 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, des, etc.
As -built of verbal OK (or e-mail to: healthdel2t@townofnorthandover.com) 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 (otber than jit*le excavafion) 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 NLDrth 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, sigWficant 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 clevation of the excavation has been reached.
h. Inspection of the sand and stone to he used.
c Fmal mspectron by Board ofHealth staff or consultant
d Instahadon of tank D -Box, pipes, stone, ven4 pump chamber, retaining waff and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as 12er the
approved plans. No instructions by the homeowner, general contractor, or pny other 12er ons shall absolve
me of this obWtion.
Undersigned Licensed Septic Installer:
(Name — Print)
(T d 's Date)
'z
(P� — Signed)
S
TOWN OF NORTH ANDOVER VOW T11
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT
1600 O�W�S�REET; Building 2-36
NORTH-A14DOVER. MASSACMJS-FTT. 1945
Susan Y. Sawyer, REHS/RS 111:66�11�:11 — Phone
Public Health Director 97 476�—* AX
M,
LOCATION INFORMATION
ADDRESS:
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
10
UCTION NOTES
jw;�� 1�elvaecs'r
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION: t 7
A
SITE CONDITIONS
Comments:
SEPTIC TANK
DExisting septic tank properly ?�doned
ElInternal plumbing all to on"ui ing sewer
F]Topography not appreciOly altered
Bottom of tank hole has stone base
Weep hole plugged
1500 gallon tank ha een installed
H-10loading M olithic construction
Ej Water tightnes f tank has been achieved
h
a0
0
f
I
'10
ad
t
e
n
in
a
p
n
tI
k
n
g
h
gg
k
M
0
e
hle
d
a
h
0
a
Iis
e
the
ic
n
tightnes of tank ha'
(Visual or Va u m Test or Water held for 24hrs)
um
t r
E] Inlet tee in alled, centered under access port
I
Ej Outlet te gas baffle or effluent filter) installed,
center under access pnort
E] 24" i h cover to within 6" of final grade installed over
onez"11
access port, must be over outlet of tank if effluent
filtk is present
El i4ydraulic cement around inlet & outlet
Wastewater System Documentation — Feb 2006
Page I of 6
TOWN OF NORTH ANDOVER %&ORTII
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT
1600
OSGOOD STREET; Building 2-36
NORTH ANDOVER, MAS SACH`USETTS 0 1845
.Susan Y. Sawyer, REHS/RS
978.688.9540 — Phone
Public Health Director
978.688.8476 — FAX
Comments:
PUMP CHAMBER
D
Bottom of tank hole has 6" stone base
F]
Weep hole plugged
0
Combo Tank installed. Size:
El
1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
El
Inlet tee installed, centered under access port
F�
Pump(s) installed on stable base
0
Alarm float working
El
Pump On/Off floats working
R
Separate on/off floats
E]
Drain hole in pressure line
El
24" inch cover to within 6" of final grade installed over
pump access port
El
Water tightness of tank has been achieved
Visual testing
Hydraulic cement around inlet & outlet
Comments:
ADVANCEDTREATMENTTECHNOLOGY
El Type of treatment device:
El Installed per manufacturers requirements
F-1 All components working in accordance with
manufacturer's requirements
Comments:
Wastewater System Documentation — Feb 2006
Page 2 of 6
TOWN OF NORTH ANDOVER
%&ORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
.., - _ 1 4
0 0
13
1600 OSGOOD STREET; Building 2-36
V.,
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. Sawyer, REHS/RS
c
978.688.9540 — Phone
Public Health Director
978.688.8476 - FAX
D -BOX
El
El
El
El
Comments:
SOIL ABSORPTION SYSTEM
E]
Comments:
Installed on stable stone base
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (notrequired)
Bottom of SAS excavated down to soil layer, as
provided on plan
Size of SAS excavated as per plan
Title 5 sand installed, if specified on plan
3/4-1 Y2" double washed stone installed
1/8-1/2" (peastone) double washed stone installed
Laterals installed and ends connected to header
Laterals vented if impervious material above
Orifices @ 5 & 7 o'clock positions
Gravel -less disposal systems: type, number and
location as per plan
Elevations of laterals installed as on approved plan
40 Mil HDPE barrier installed
Retaining wall (boulder / concrete / timber/ block)
Final cover as per plan
Wastewater System Documentation — Feb 2006
Page 3 of 6
TOWN OF NORTH ANDOVER
t4oRTIJ
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MAS SACHUSETTS 0 1845
Susan Y. Sawyer, REHS/RS
c U
978.688.9540 — Phone
Public Health Director
978.688.8476 — FAX
PRESSURE DISTRIBUTION
10
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
CONTROLPANEL
F-1 Alarm & Pump are on separate circuits
0 Alarm sounds when float is tripped
El Location of control panel:
Comments: F1 Rated for exterior if placed outside
Wastewater System Documentation — Feb 20G6
Page 4 of 6
TOWN OF NORTH ANDOVER %40RTII
". . 9 '-.6
Office of COMMUNITY DEVELOPMENT AND SERVICES
11EALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 0 1845 C U
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
1 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 3 10 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
Tank
SAS Sewer
El
Property line
10
10
0
Cellar wall
10
20
11
Inground pool
10
20
El
Slab foundation
10
10
El
Deck, on footings, etc
5
10 --
0
Waterline
10
10 101
EJ
Private drinking well
75
1002 50
El
Irrigation well
75
100
El
Surface Water
25
50
Bordering Vegetated Wetland
Salt Marsh, Inland / Coastal Bank3
75
100
El
Wetlands bordering surface
water supply or trib. (in Watershed)
150
150
El
Trib. to surface water supply
325
325
El
Public well
400
400
R
Interim Wellhead Prot. Area
0
Reservoirs
400
400
El
Drains (wat. supply/trib.)
50
100
0
Drains (intercept g.w.)
25
50
El
Drains (Other) Foundation
10(5)
20(10)
F-1
Drywells
20
25
1 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 3 10 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
a
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
o
#-
HEALTH DEPARTMENT ,,
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 0 1845 SAC US
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
0
Town of North Andover
HEALTH DEPARTMENT
S CHU
CHECK P#TE:
LOCATION:
1-1/0 NAME:
N A M E -� � 'X; --- # �
Type
of Permit or License: (Check box)
0 Septic - Design Approval
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$-
0
Food Service - Type:
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$-
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrasIVSolid Waste Hauler
$-
0
Well Construction
$
SEP77C Sustems:
0 Septic - Soil Testing
$
0 Septic - Design Approval
$
0 Septic Disposal Works Construction (DWQ
$
13 Septic Disposal Works Installers (DWI)
$-
0 Title hispector
�title 5 IR'eport
$
7j)
e
$
0 Other (Indicate) $
A
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
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.
fAff
Commonwealth of Massachusetts
Title 5 Official Inspection Flo
Subsurface Sewage Disposal System Form - Not for Voluntary)
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
Cityrrown
MA 01845
State Zip Code
RECEIVED
antAUG 112009
'WN OF NORTH ANInAVI
HEALTH 6E�k�i E T
8/1/2009
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 Arailla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
Ma
State
S115
License Number
01810
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
F� Passes 0 Conditionally Passes El Fails
El N Further Evaluation by the Local Approving Authority
8/1/2009
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 DER 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
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845
State Zip Code
8/1/2009
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
El 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.
El Y 0 N 0 ND (Explain below):
t5ins - 09/08 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover MA 01845 8/1/2009
Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
D 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):
El broken pipe(s) are replaced
El obstruction is removed
Ej Y Z N El ND (Explain below):
EJ Y Z N F-1 ND (Explain below):
EJ distribution box is leveled or replaced El Y Z N 0 ND (Explain below):
El 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):
[I broken pipe(s) are replaced El Y Z N [:1 ND (Explain below):
El obstruction is removed El Y Z N [I ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El 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(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El 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
a.
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Tifle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
Cityfrown
B. Certification (cont.)
MA 01845
State Zip Code
8/1/2009
Date of Inspection
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:
EJ 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.
El 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.
El 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:
Outlet tee in septic tank needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
El N Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El N Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El N 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 Y2day flow
t5ins - 09/08 Title 5 Official Inspection Form: 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
261 Carlton Lane
Property Address
James Bryant
Owner Owners Name
nformation is
required for North Andover MA 01845 8/1/2009
very page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El E 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.
El E Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
EJ E Any portion of a cesspool or privy is within a Zone 1 of a public well.
El E Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
El E 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.]
z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
z The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CM R 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
El El the system is within 400 feet of a surface drinking water supply
11 El the system is within 200 feet of a tributary to a surface drinking water supply
El D the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
i
e
z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
z The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CM R 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
El El the system is within 400 feet of a surface drinking water supply
11 El the system is within 200 feet of a tributary to a surface drinking water supply
El D the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
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
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
Cityfrown
C. Checklist
MA 01845 8/1/2009
State Zip Code Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
0 El
Pumping information was provided by the owner, occupant, or Board of Health
El E
Were any of the system components pumped out in the previous two weeks?
[I El
Has the system received normal flows in the previous two week period?
El Z
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z 0
Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
Z El
Was the facility or dwelling inspected for signs of sewage back up?
E El
Was the site inspected for signs of break out?
Z 0
Were all system components, excluding the SAS, located on site?
N El
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?
Z E]
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:
N El
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
�L\' Commonwealth of Massachusetts
9�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owner Owners Name
information is
required for North Andover MA 01845
every page. City[Town State Zip Code
t5ins - 09/08
D. System Information
Description:
Number of current residents:
8/1/2009
Date of Inspection
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonaluse?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
El
Yes
Z
No
El
Yes
Z
No
El
Yes
E�
No
El
Yes
0
No
Yes
El Yes Z No
Current
Date
F�
Yes
El
No
F-1
Yes
No
F-1
Yes
No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
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
8/1/2009
Date of Inspection
Pumped June 2009, owner
gallons
Type of System:
z Septic tank, distribution box, soil absorption system
El Single cesspool
11 Overflow cesspool
n Privy
El Yes Z No
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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
El Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Property Address
James Bryant
Owner
Owners Name
information is
required for
North Andover MA 01845
every page.
Cityrrown State Zip Code
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
8/1/2009
Date of Inspection
Pumped June 2009, owner
gallons
Type of System:
z Septic tank, distribution box, soil absorption system
El Single cesspool
11 Overflow cesspool
n Privy
El Yes Z No
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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
El Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 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
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
CityrFown
D. System Information (cont.)
MA 01845
State Zip Code
8/1/2009
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
24 years old, 6/11/1985, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
F-1 cast iron E 40 PVC El other (explain):
Distance from Drivate water supply well or suction line:
2
feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC thru floor, 3" PVC in house, no leaks visible
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete El metal
0 Yes E No
5
feet
El fiberglass El polyethylene El 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'x4'
Sludge depth:
t5ins - 09/08
N
D Yes El No
Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Owner
information is
required for
every page.
t5ins - 09108
Commonwealth of Massachusetts
Tit le 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owner's Name
North Andover
Cityrrown State
D. System Information (cont.)
01845
Zip Code
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
8/1/2009
Date of Inspection
2711
1
IVI
Distance from bottom of scum to bottom of outlet tee or baffle 15"
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 tee ok. Outlet tee badly corroded, needs to be replaced. Depth of liquid at outlet invert. No
evidence of leakage. Inlet & outlet covers has risers 3" deer).
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal
El fiberglass
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
feet
El polyethylene El other (explain):
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
ijroperty ACareSS
James Bryant
Owners Name
North Andover
Cityrrown
MA 01845
State Zip Code
8/1/2009
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:
LJ concrete El metal El fiberglass El polyethylene El other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: [I Yes Fj No
Alarm level: Alarm in working order: [I Yes Fj No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? n Yes El No
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Tit le 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
City/Town
D. System Information (cont.)
MA 01845
State Zip Code
8/1/2009
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 & distibution equal. No evidence of leakage. Evidence of carryover. D -box cover broken
replaced it.
Pump Chamber (locate on site plan):
Pumps in working order: D Yes F1 No
Alarms in working order: F� Yes F-1 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Owner
information is
required for
every page.
t5ins - 09108
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
RAA
Cityrrown State
D. System Information (cont.)
Type:
11
leaching pits
El
leaching chambers
leaching galleries
leaching trenches
El
leaching fields
El overflow cesspool
11 innovative/alternative system
01845 8/1/2009
Zip Code Date of Inspection
number:
number:
number:
number, length:
number, dimensions:
number:
2 trenches 58'
long
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.
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
El Yes Fj N o
Title 5 Offirial inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
<L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Owner
information is
required for
every page.
Property Address
James Bryant
Owners Name
North Andover
Cityrrown
MA 01845
State Zip Code
8/1/2009
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
Owner
information is
required for
every page.
t5ins - 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owner's Name
North Andover MA 01845 8/1/2009
Cityfrown 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
'0
L4 6,3
D
Is
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owners Name
North Andover
City/Town
D. System Information (cont.)
Site Exam:
0 Check Slope
Surface water
Check cellar
Shallow wells
Estimated deDth to high around water:
MA 01845
State Zip Code
4
8/1/2009
Date of Inspection
feet
Please indicate all methods used to determine the high ground water elevation:
1031
M
I
Obtained from system design plans on record
If checked, date of design plan reviewed- 3/15/1985
bate
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 test pit data from design plan.
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
<C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owner Owners Name
information is
required for North Andover MA 01845 8/1/2009
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
Z 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
Size Total 101 Sin—gle
FY 1.05 Acres
2009
US lm!.q��H�inlndex
Ramelddress
BRYANT, JAMES
261 CARLTON LANE
N. ANDOVER, MA
01845
US Account M -
i—c---
a i n t.
count No Cycle
Bldg Id. 14176.0 - 261 CARLTON LANE
2100161
02 Cycle 02
U13 Services M int.
Account No' 2100161
Service Code
MISCFEE ADMIN FEE
WTR WATER
US Meter Mainten
b Badger
Account No. 2100161
w Water
Consumption Posted Date
Serial No Status
1
29821501 a Active
44
Date
5/6/2009
Reading
2/3/2009
615
11/3/2008
608
8/1/2008
607
5/1/2008
563
2/6/2008
537
11/1/2007
523
8/3/2007
506
5/3/2007
410
2/21/2007
331
11/1/2006
315
8/1/2006
294
5/4/2006
234
2/1/2006
177
11/1/2005
156
8/4/2005
140
5/2/2005
63
2/2/2005
36
11/3/2004
18
11/3/2004
0
8/10/2004
2069 r
Trouble Code:03
2045 a
5/13/2004
"110 uard generated on 7/29/2009 3:00:41 PM by Karen Hanlon
Town of North Andover
Tax map # 210-107-A-0212-0000.0
Parcel Id 18042
261 CARLTON LANE
BRYANT JAMES
261 CARLTON LANE
N. ANDOVER, MA
01845
Type
Type Loan Number
Payor Active/Inact. From
Occupant Name
Last Billing Date 6/4/2009 Active/inactive
Active
Rate
0.635/8 Charge multiPlier/Users
01 ALL METER SIZE 7.82
23,73
Location
ERT HH
Code
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
a Actual
n New Meter
Replacement
Actual
Trouble Code:03 4VV2 a Actual
2/17/2004 1982 a Actual
Brand
b Badger
Type
w Water
Consumption Posted Date
7 6/16/2009
1
3/16/20og
44
12/10/2008
26
9/12/2008
14
6/18/2o08
17
3/14/2008
96
1/15/2008
79
9/14/2007
16
6/26/2007
21
3/23/2007
60
12/22/2006
57
9/13/2006
21
6/20/2006
16
3/13/2006
77
12/14/2005
27
9/12/2005
18
6/8/2005
18
3/15/2005
0
12/17/2004
24
12/17/2004
43
9/20/2004
20 6/14/2004
23 4/16/2004
Size
0.630.63
Page I
Until
YTD Cons
78
Variance
600%
-98%
66%
72%
-6%
-84%
24%
281%
20%
-71%
2%
181%
31%
-80%
201%
42%
2%
-100%
-100%
-42%
108%
3%
0%
Z\, Commonwealth of Massachusetts
RECEIVED
City[Town of
System Pumping Record
Form 4 JUN 3 o 2009
N OF -NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Othe Nacmao@Aft E
information must be substantially the same as that provided here. usingag this 'form-, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
1. System Location: Left front, left rear, left side of hous right rear, right sidg��D
Address
Cityrrown
2. System Owner:
Name
Address (if different from
City/Town
State
Zip Code
Sta!3�,a 7. p C
n7?7
Telephone Number
B. Pumping Record -a3
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) 0-te-ptic Tank Tight Tank
[] Other (describe):
4. Effluent Tee Filter present? 0 Yes 2r-N`o-
5. Condition of System- 1
Y,\ (�K 144jv�
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location -where contents were disposed:
t-'- ��16. �D( Lowell Waste Water
If yes, was it cleaned? [I Yes Cj No
2
F 5821
Vehicle License Number
, -1
TA
of Rjuthr Date
t5form4.doc-.06/03 System Pumping Record - Page 1 of I
SYSTEM PUMPING
DATE: It
SYSTEM OWNER & ADDRESS
RECE�IVE�D
NOV IS 2005
OF N R HAND
LT 0 T
P Tu�::2VER
L : !HIE"A H D E A R 'r I
SYSTEM LOCATION
(example: left front of hous
DATEOFPUMPING' U—t(�7�UANTFWPUMIPED:
/ 6-?-It�GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ---�EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFI[ELD RUNBACK
FLOODED
OTBER (EXPLAIN)
sysTEm PumPED BY: Bateson Enterprises, Inc.
CONMENTS:
CONTENTS TRANSFEMED To: G.L.S.1) L-" Lowell Waste
DATE:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
to, -5-0 D
R&ADD
,�;rsAr'
a6
SYSTEM LOCATION
(example: left front of house)
DATEOFPUMPING: tbf�.' O�QUANTITY PUMPED rS-'GALLONS
CESSPOOL: NO ---�S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: C. J�),
Commonwealth of Massachusetts
0' "-WMassachusetts
System Pumpigg Record
System Owner,
Date of Pumping: ( — 9 C�
Cesspool: N o Yes Ll
System Location
c�
L -01 -
Quafitity Pumped:
Septic Tank: No 11
System Pumped by: getrejart Sffaf�ftaw License #
Contents transrertred to : Greater Lawrence Sanitary District
Date:
Inspector:
1!;-�--,�gallons
Yes 1�1
-3!0. -
0
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner
V)-� �r�
Date of Pumping:
Cesspool: No Yes U
System Location
1, C
0
Quantity Pumped: /5-��4allons
Septic Tank: No Yes�
System Pumped by: 64w" 46d&014W License #
Contents transrerrred to : Greater Lawrence Sanitary District
Date: Inspector:
,Nv4R,o- Ezevoq Hoev-S,
.5cuo.t,k O&At—MI5-a-
1*6NA 6y— 124-af
,ta/vg ou .0
A
jg — //— 49s—
49 Z
8'�04 W �U
v—ck. ma
CwO
rn
/ A# r Ole ,
TO: NORTH ANDOVER, MASS 19
BOARD OF HEALTH
Re: Soil Absorption Sewage
F ROM: DESIGN ENGINEER System Inspection
This is to certify that I have inspected the construction of the said disposal system at
L -'t 4 4 C"' A R L Y-0 �U � /- 4 /V E North Andover, Mass.
SITE LOCATION '
The grades and construction are as specified in my plans and specifications dated
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SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT
APPROVED DATE
Provided:
DISAPPROM DATE
Reasons:
PvC -z95
Title V
FA11
Reg 2.5
L/
The submitted plan must show as a minimum:
the lot to be served-area,9dimenaions lot # abutters
b location and log deep observation Mes-disi9tance to ties
c location and results percolation tests -distance to ties
di design calculations & calculations showing required leaching area
location and dimensions of system -including veBerve, area
,(a)
(f) existing and proposed contours
I
VI/
location any wet areas -Athin 1001 of sewage disposal system or
'(g)
disclaimer -check wetlands mapping
(h), surface and subsurface drains within 1001 of sewage disposal
system or disclsimer
location any drainage easements vithin 1001 of sewage disposal
system or disclaimer -Planning Board files
knom sources of water supply within 2MI of sewage disposal
system or disclaimer
location of any proposed well to serve lot -1001 from leaching facility
location of water limes on property -101 from leaching facility
7(l)
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevationB of basement.9 plumb't pipe., septic tank,,
Astribution box inlets and outlets,, distribution field piping and
V
0 er elevations
Maximum ground water elevation in area sewage disposal system
s) plan mast be prepared by a Professional Engineer or other
tl
professional authorized by law to prepare such- plans
Reg 6
Septic Tanks
(a) capacities -150% of flow., water table.. tees., depth of tees.,
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access., pumping
(b) cleanout
(c) 101 from cellar van or inground swimming pool
vi
251 from subsurface drains
71(d)
Reg 10.2 Distribution Boxes
1 -1 11(a) slope greater ME 0.08
Reg 10.4 =3(b) mup
Health
.4bdo"r.,Mas
SUBSURFACE DISPOSAL DESIGN CHECK L1q.
1OT
APPRom un zLt-� 5 DISOPROVIM DATE
Provided: Reasonsi
k
Title V
FAIL
09
Reg 2.5
The submitted plan must show as a TA mi nimi
the lot to be served -areas, dimensions lot #sabuttera;
b location and log deep observation Mes-distance to ties
C location and results percolation testa -distance to ties
di design calculations & calculations showing requirc7d leaching area
—,a)
location and dimensions of system-incluAing reserve area
'(e)
exiating and proposed contours
_(f)
10 ation any vet areas within 1001 of seoage disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 10C I of sewage disposal
system or disclaimer
location any drainage easements within 1 )01 of sewage disposal
system or disclaimer -Planning Board file Y
(J) known sources of water supply within '.'M' of sewage disposal
tem or disclaimer
(k) lao7esation of any proposed wel.1 to serve loT, 1001 from leaching facility
(1) location of water lines on property -101 from leaching facilit7
(m) location of benchmark
(n) driveways
(o) garbage disposals
) no PVC to be used in construction
q) profile of system-elevationa of basements, plumbs, pipe., septic tank,
distribution box inlets and outlets., distribution field piping and
otter elevations
(r) max1mum ground water elevation in area sewne disposal system
plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such. plans
,(a)
Reg 6
Septic Tanks
(a) capacities -150% of flow., water tables tt asp depth of teesp
accessp punping
(b) cleanout
(c) 101 from cella.r wa2_1 or inground suimmirg pool
(d) 251 from subsurface drains
Reg 10.2
Reg 10.4
Distribution Boxes
(a) slope greater than 0.08
sup 1 16
::3b)
Bo, &rd o f T1 a al th
North An(io-i2��,Y-�Bsq
AP11ACIVED DATE
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SEPTIC SISTEM AJ
INSTAMATICK CM3CK LI ST LOT
DI SATPROVED 9AVATICK 011 FATL
Gasonst
1. 'Distance To:
a. We t1an ds
b. Drains
wen
2. Water Line Location
3.- No PVC Pipe
4. Septic Tank
a. Tees m--Longth & 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 Flo-Amg Equal AMO'-Ints
c. No Back Flow
6. - Leach Field or Trench
a. Dimensions
b. Stone Depth
c *- Capped Ends
d. Cle-an Double washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cen, ant, Pipe to Pit - Both Si11P
f. Clean Doub'je Washed Stone
8. No Garbage Disposal
9. M...nal Grading Inspection
10. Barricading Covexed System
11. As Built Submitted
a. Lot, Loc-ation
b. Dixensions of System
c. Location with Regard-tO Pere Test
d. 'Elevations
e 0' Water Table
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