HomeMy WebLinkAboutMiscellaneous - 268 RALEIGH TAVERN LANE 4/30/2018 (2)N.,
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CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit# 2- -7
Plan Approval: Date: Approved b
Designer: r�n:�4_ —Plan Date:
Conditions:
Water Supply. Town. Well.
Well Permit: Driller:
Well Tests: Chemical Date -Approved
Bacteria I Date7APoroved
Bacteria. U Date�_Approved
Plumbing. Sip -Off. -Wiring Sign -Off -
Comments:
Form "U' Approval: Approval to -Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
-All P er�nits Paid?
NO
Well Construction Approval?
NO
Septic System Construction Approval?
NO
Certification?
NO
Other
YES
Any Variance Needed?
YES
NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
SEPTIC SYSTEM INSTALLATION
Is the installer licensed? YES NO
jype of Construction:
NEW Eki��
:--�,--N.emrConstruction-:--C�ertified Plot Plan Review YES NO
-L-FIbbrPlm Review YES NO
C6hditi6m oEApproval. fro F-
m orm U YES NO
YES
NO
L—YE-S NO-
__DWC;Permit PaidT
"--Installer:"'--
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bnstruction''Inspection:
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;_.;t;�aFGra`dingApprbval:': at LE By:
D e
zo
Construction Approval-.' D' ate:' By:
WE&
Ceiglicate of Compliance:, Appr v
ov Date:
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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
NAR 312001144
TOwr-j OF ' "di�i� 111 ANDOVER �i
HEALT:i DEPARTMENT
3/24/2014
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
Cityrrown
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:
Z Passes El Conditionally Passes F-1 Fails
El Reeds WFurthn r Evaluation by the Local Approving Authority
3/24/2014
In: or Signatu 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 - 3/13 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
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner's Name
North Andover MA 01845 3/24/2014
Cityf'rown 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:
Z 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:
13) System Conditionally Passes:
El 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 exfli tration 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 F1 N F� ND (Explain below):
t5ins - 3/13 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
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner's Name
North Andover
CityrFown
B. Certification (cont.)
MA 01845 3/24/2014
State Zip Code Date of Inspection
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
E] 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):
0
F-1
r-1
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
El Y
El Y
F1 Y
El N
El N
F-1 N
El
0
[I
ND (Explain below):
ND (Explain below):
ND (Explain below):
El The system required pumping more than 4 times a year due to broken
system will pass inspection if (with approval of the Board of Health):
0 broken pipe(s) are replaced [I Y F1 N 0
r-1 obstruction is removed F-1 Y F1 N El
or obstructed pipe(s). The
ND (Explain below):
ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
F-1 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
45ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
-C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner Owners Name
information is
required for North Andover MA 01845 3/24/2014
every page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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:
F-1 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.
E] The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
F� 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 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 must
be attached to this form.
3. Other:
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
Z
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
1:1
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
0
z
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
1:1
z
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
<f
X,
Commonwealth of Massachusetts
X
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner
Owners Name
information is
required for
North Andover
MA 01845 3/24/2014
every page.
Cityrrown
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
1:1
z 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
Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
El
Z Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
EJ
Z 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.]
El Z The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
z The system falls. 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
El 1:1 the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
E] 0 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 - 3/13 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
268 Raleigh Tavern Lane
11roperty Address
Michael Po
Owners Name
North Andover
CftyfTown
C. Checklist
MA 01845
State Zip Code
3/24/2014
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Z El
Pumping information was provided by the owner, occupant, or Board of Health
0 E
Were any of the system components pumped out in the previous two weeks?
Z El
Has the system received normal flows in the previous two week period?
[I Z
Have large volumes of water been introduced to the system recently or as part of
this inspection?
• El
Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
• El
Was the facility or dwelling inspected for signs of sewage back up?
• El
Was the site inspected for signs of break out?
Z 0
Were all system components, excluding the SAS, located on site?
Z 11
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 El
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:
Z El
Existing information. For example, a plan at the Board of Health.
Z 11
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):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
440
t5ins - 3/13 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
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner Owner's Name
nformation i's
required for North Andover MA 01845 3/24/2014
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? Yes No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes N No
information in this report.)
Laundry system inspected? El Yes F-1 No
Seasonaluse? D Yes 0 No
Water meter readings, if available (last 2 years usage (gpd)): Yes
Detail:
Sump pump? El Yes Z No
Last date of occupancy: Current
Date
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?
[I
Yes
F1 No
Industrial waste holding tank present?
EJ
Yes
El No
Non -sanitary waste discharged to the Title 5 system?
0
Yes
El No
i
Grease trap present?
[I
Yes
F1 No
Industrial waste holding tank present?
EJ
Yes
El No
Non -sanitary waste discharged to the Title 5 system?
0
Yes
El No
Water meter readings, if available:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspect on orm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
268 Raleigh Tavelm Lane
Property Address
Michael Po
Owner Owners Name
information is
uired for North Andover MA 01845 3/24/2014
every page. CityfTown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
State Zip Code
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Date
Pumped 2012, owner
1500
gallons
Measured tank.
Date of Inspection
Reason for pumping: Inspect tank & tees.
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
Overflow cesspool
Privy
E] 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
E] Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 3113 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
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner Owners Name
information is
required for North Andover MA 01845 3/24/2014
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
16 Years old, 9/21/1998, as built plan
Were sewage odors detected when arriving at the site? El Yes Z No
Building Sewer (locate on site plan):
Depth below grade: 2
feet
Material of construction:
Z cast iron Z 40 PVC F� other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" Cast iron through wall, 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete El metal
[:1 fiberglass
1
feet
El polyethylene [:1 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:
41'
El Yes E] No
t5ins - 3/13 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
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner
information is
required for
every page.
t5ins - 3113
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
3/24/2014
State Zip Code Date of Inspection
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29"
Scum thickness 41 -
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle 91,
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence
of leaka_qe. Inlet cover has riser 3" deel)
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
F� concrete - El metal
feet
El fiberglass 0 polyethylene 0 other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 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
268 Raleigh Tavem Lane
Property Address
Michael Po
Owners Name
North Andover MA 01845 3/24/2014
Cityrrown 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:
El concrete El metal 0 fiberglass El polyethylene [] other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes [] No
Alarm level: Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
El Yes D No
* Attach copy of current pumping contract (required). Is copy attached? F-1 Yes f-1 No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
MFEW
I La
1V I
'I LI-R-19ji,
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
268 Raleigh Tavem Lane
Property Address
Michael Po
Owners Name
North Andover MA 01845 3/24/2014
Cityrrown - State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box level & distribution equal, has flow equalizers. Evidence of carryover, pumped
d -box to clean. No evidence of leakaqe.
Pump Chamber (locate on site plan):
Pumps in working order:
0 Yes E] No*
Alarms in working order: 0 Yes El No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
268 Raleigh Tavern Lane
-Property Address
Michael Po
Owners Name
North Andover
CityrFown
D. System Information (cont.)
State
01845
Zip Code
3/24/2014
Date of Inspection
Type:
11 leaching pits
number:
11 leaching chambers
number:
0 leaching galleries
number:
0 leaching trenches
number, length: 5 trenches 25'
long
11 leaching fields
number, dimensions:
El 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.):
Yard covered in snow, 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 0 Yes Fj No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
268 Raleigh Tavern Lane
Property Address
Michael Po
Owners Name
North Andover MA 01845 3/24/2014
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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
268 Raleigh Tavern Lane
Property Address
Michael Po
Owners Name
North Andover
MA 01845
3/24/2014
City[Town 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
L4
-Q�
t5ins - 3/13 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
268 Raleigh Tavem Lane
Property Address
Michael Po
Owners Name
North Andover
CityTrown
D. System Information (cont.)
Site Exam:
Z Check Slope
Z Surface water
Z Check cellar
0 Shallow wells
Estimated depth to high ground water:
MA 01845
State Zip Code
4
feet
3/24/2014
Date of Inspection
Please indicate all methods used to determine the high ground water elevation:
N Obtained from system design plans on record
If checked, date of design plan reviewed: 6/3/1998
Date
F-1 Observed site (abutting property/observation hole within 150 feet of SAS)
z Checked with local Board of Health - explain:
Design plan
El Checked with local excavators, installers - (attach documentation)
F-1 Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins, - 3/13 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
268 Raleigh Tavern Lane
Property Address
Michael Po
Owner
information i's
required for
every page.
Owner's Name
North Andover MA 01845 3/24/2014
Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System Information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3/13 Title 5 Offirial Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
-1-\ Commonwealth of Massachusetts
City/Town of
Sys'tem Pumping Record
Form 4
DEP has provided this form'for use4by local Boards of Health. Other forms may be'used, but the
information, must be substantially the tame as that provided here. Before using this form, check with your
local Board of Health to determine the fbrm they use. The System Pumping Record must be submitted to
the local Board of Health, or other approving authority.
A. Facility. Information
1. System Location: Left/ Right front of house, Left/ Right'rear of house,d oeft rightCg� �ofhou�seft
Right side of building, - Left / Right fr6nt of building, Left / Right mar of building, Under deck
Address lip '4e":6
2CA oo
Cityrrown state Zip Code
2. System Owner
iame
Address (if different from location)
Cftyfrown
f -P gode
Telephone Number
Be Pumping Record
1. Date of Pumping
3. Type -of system,.- [:]
4.
Date Quantity Pumped:
Gallons
Cesspool(s) a-Se�ptc �'ank El Tight Tank
Other (describe):
Effluent Tee Filter present? E] Yes 9,"ho If. yes, was It cleaned? [I Yes [I No
'5. Condition of System:
6. System Pumped By.
Nell. Bateson
Name
Bateson EhterDrises Inc -
Company
7. L t' ion,�I_ re contents were disposed:
L Lowell Waste Water
F5821
Vehicle License umber
bate
t5formil.doce 06/03
System Pumping Record - Page I of I
41,
Summary Record Card generated on 3/19/2014 2:18:15 PM by Maureen McAuley Page 1
Town of North Andover
Tax Map # 210-106.C-0109-0000.0
Parcel Id 17742
268 RALEIGH TAVERN LANE
MICHAEL A PO, SUSAN T PO
268 RALEIGH TAVERN LANE
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential ZonIng3 1 Residential
Size Total 1 Acres
FY 2014
UB Mailina Index
Name/Address Type Loan Number Active/Inact. From Until
MICHAEL A PO, SUSAN T PO Owner
268 RALEIGH TAVERN'LANE
NORTH ANDOVER, MA
01.845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 14106.0 - 268 RALEIGH TAVERN LANE Last Billing Date 3/6/2014
2100086 02 Cycle 02 Active
UB Services Maint.
Account No. 2100086
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 53.20 /1
UB Meter Maintenance
Account No. 2100086
Serial No
Status
Location
Brand
Type Size
YTDc`p�ni:
41"
36433650
a Active
ERT HH
b Badger
w Water 0.630.63
-
596
bate
Reading
Code
Consumption
Posted Date
Variance
2/3/2014
601
a Actual
14
3/17/2014
10/31/2013
587
a Actual
48
12/20/2013
47%
8/1/2013
539
a Actual
33
9/18/2013
35%
5/1/2013
506
a Actual
22
6/18/2013
6%
2/7/2013
484
a Actual
25
3/13/2013
-49%
10/30/2012
459
a Actual
44
12/13/2012
-33%
8/2/2012
415
a Actual
68
9/26/2012
177%
5/212012
347
a Actual
24
6/20/2012
-51%
2/2/2012
323
a Actual
51
3/14/2012
7%
11/1/2011
272
a Actual
47
12/15/2011
-12%
8/1/2011
225
a Actual
53
9/14/2011
111%
5/2/2011
172
a Actual
24
6/13/2011
5%
2/4/2011
148
a Actual
25
3/15/2011
-55%
11/1/2010
123
a Actual
53
12/13/2010
36%
8/2/2010
70
a Actual
39
9/13/2010
50%
5/3/2010
31
a Actual
26
6/9/2010
37%
2/1/2010
5
a Actual
5
3/11/2010
-100%
1/8/2010
0
n New Meter
0
3/11/2010
-100%
1 ?8/2010
5766
r Replacement
15
3/11/2010
-38%
1162009
5751
a Actual
33
12/11/2009
4%
8/3/2009
5718
a Actual
31
9/11/2009
0%
5/6/2009
5687
a Actual
32
6/16/2009
967%
2)3/2009
5655
a Actual
3
3/16/2009
-94%
11/3/2008
5652
m Manual estimate
50
12/10/2008
-38%
MSG
8/1/2008
5602
a Actual
79
9/12/2008
647%
5/1/2008
5523
a Actual
10
6/18/2008
-58%
2/4/2008
5513
m Manual estimate
26
3/14/2008
-66%
MSG
/61/+3
HAY 2 2,2014
CON NORTHANDOVER
�E-RVATION COMMISSION
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
This is to certify that
the individual subsurface disposal system
constructed ( ) or repaired ( x )
by North Andover Licensed Installer
Todd Bateson
at
268 Raleigh Tavern Lane, North Andover, MA 01845
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Permit# 1027 dated June 5, 1998.
1
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
'.1
MAY 2 2 -2014
NORTH ANDOVER
CONSERVATION COMMISSION
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The d i ed hereby certify that the Sewage Disposal System constructed-
(,�u ( ersign
repaired;
located at J6 y P14 Le- (' r/ � T4 a -A 4 '1 A`1_0'
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit #jLAj),, dated S�_eo � & , /fty with an approved design
flow of 416 gallons per day. The materiafs used were in conformance with those
specified on the approved plan; the system was installed in accordance with the provisions
of 3 10 CNIR 15. 000, Title 5 and local regulations, and the final grading agrees
substantially with the approved plan. All work is accurately represented on the As -built
which has been submitted to the Board of Health.
Bed inspection date:. 7— / 7— 7'r
Final inspection date: 7— J7) -- ? y
Installer: 77-;,a (2yq- /4.5 e"i
Engineer Representative
Engineer Representative
LicA &�- 90-:rDate: 77
Design Engineer: nAA.1 ko T_ 4 L/d 5 Date:
e S4)
.Per
, V a., .' .
Massachusetts Department of Environmental Protection DEP File Number:
Bureau of Resource Protection - Wetlands
WPA Form 8A - Request for Certificate of Compliance , oLLV-0--
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
A. Project Information
Important: MAY 2 2 2014
When filling out 1. This request is being ade by:
forms on the GO NORTH ANDOVER
computer, use NSERVATION 0 ImmuVIVIV I
only the tab Name 11 122222! 1
key to move 75'��
your cursor - Mailing Address
do not use the AJ 4AJb6�Jt_PZ
return key. CityTrown State Zip Code
0--h 9?9
4�::A Phone Number
2. This request is in reference to work regulated by a final Order of Conditions issued to:
7YU S.
Applicant
---s
Dated DEP File Number
Upon completion
of the work 3. The project site is located at:
authorized in V_'� lave_r-(\ Lavj- ikJo er-
an Order of Street Address City[Town
Conditions, the
property owner 1(0 C_
must request a Assessors Map/Plat Number Parcel/Lot Number
Certificate of 4. The final Order �f Conditions was recorded at the Registry of Deeds for:
Compliance I
from the issuing 0 _'C'
authority stating Property Owner (if different)
that the work or
portion of the Na��S-cy -0c) C7�k
work has been County Book Page
satisfactorily
completed. Certificate (if registered land)
5. This request is for certification that (check one):
Pr"the work regulated by the above -referenced Order of Conditions has been satisfactorily completed.
El the following portions of the work regulated by the above -referenced Order of Conditions have
been satisfactorily completed (use additional paper if necessary).
the above -referenced Order of Conditions has lapsed and is therefore no longer valid, and the
work regulated by it was never started.
wpaform8a.doc -- rev. 7/13/04 Page 1 of 2
LlMassachusetts Department of Environmental Protection DEP File Number:
Bureau of Resource Protection - Wetlands
WPA Form 8A — Request for Certificate of Compliance Provided by DEP
Massachusetts Wetlands Protection Act M.G.L. c. -131, §40
A. Project Information (cont.)
6. Did the Order of Conditions for this project, or the portion of the project subject to this request, contain
an approval of any plans stamped by a registered professional engineer, architect, landscape
architect, or land surveyor?
M/Yes If yes, attach a written statement by such a professional certifying substantial
compliance with the plans and describing what deviation, if any, exists from the plans
approved in the Order.
0 No
B. Submittal Requirements
Requests for Certificates of Compliance should be directed to the issuing authority that issued the final
Order of Conditions (OOC). If the project received an OOC from the Conservation Commission, submit
this request to that Commission. If the project was issued a Superseding Order of Conditions or was the
subject of an Adjudicatory Hearing Final Decision, submit this request to the appropriate DEP Regional
Office (see hftp://www.mass.qov/dep/about/region/findyour.htm).
wpaform8a.doc -- rev. 7/13/04 Page 2 of 2
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: CURRENT INSTALLER'S LICENSE#
LOCATION: /,-/ 7,-4v,%eAj -
LICENSED INSTAUER:_ 7�7,QPD __BA7—e5,Q,()
SIGNATURE:- y4i/�___P:�42��_TELEPHONE# 4/ 7,yr
CHECK ONE:
REPAIR:
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUIELT.
Administrative Use Only
$75.00 Fee Attached? Yes V/ No
Foundation As -Built? Yes No
Floor Plans? Yes No
Approval Date-.
ne
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
Th
(,�q dersigned hereby certify that the Sewage Disposal System constructed;
by repaired; C
located at J6 Y R,4 Le. ('4� T4t/.A r^j � A
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit #jgjL dated S�ep � // , /J�y with an approved design
flow of 416 gallons per day. The materia& used Were in conformance with those
specified on the approved plan; the system was installed in accordance with the provisions
of 3 10 CMR 15. 000, Title 5 and local regulations, and the final grading agrees
substantially with the approved plan. All work is accurately represented on the As -built
which has been submitted to the Board of Health.
Bed inspection date: 7 - / 7 - P"
Final inspection date: �—_ cyd _ ? Y -
Installer: _/ .0a &143eAj
AJ(
Engineer Representative
( A/10 Ar4
4�1 I -
Engineer Representative /
Lic. 9: AL go -%-Date: 77
Design Engineer: �)AjV #'0' L/d 5 Date:
(�,-eeri_ 47
21. s,
AS -BUILT CHECKLIST
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOT NUMBER, STREET NAME
W/fN 150'OF SYSTEM
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATION & DEMENSIONS OF SYSTEM,
INCLUDING RESERVE
TEES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
W/fN 150'OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
STAND & SIGNATURE
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
FINAL CONTOURS
LOCATION & ELEVATION OF BENCHMARK USED
LOCUSPLAN
Town of North Andover
OMCE OF
COMMUNITY DEVELOPMENT AND SERVICES
30 School Street
WILLIAM J. SCO17 North Andover, Massachusetts 0 184 5
Director
June 29, 1998
Bill Dufresne
Merrimack Enguileering Services
66 Park Street
Andover, MA 0 18 10
Dear Mr. Dufresne:
This is to notify you that the proposed septic plans for the repair of the system at 268
Raleigh Tavem Lane have been approved.
If you have any questions, please do not hesitate to call the office.
Sincerely,
Sandra Starr, R.S.
Health Administrator
Cc: Wm. Scott, Dir. CD&S,
Larry Lyons
File
T
0
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
PLAN REVIEW CHECKLIST
ADDRESS T�L) ENGINEER_
GENERAL
3 - COPIES STAMP LI -11, LOCUS Ll---�NORTH ARROW L-"'� SCALE
CONTOURS PROFILE----- (Sc) SECTION i-� BENCHMARK i,— SOIL &
PERCS. ELEVATIONS WETS. DISCLAIMER WELLS & WETS
WATERSHED? VK) DRIVEWAY C---- WATER LINE C-� FDN DRAIN '�-' M&P
SCH40 TESTS CURRENT? SOIL EVAL DuF)eggslu
SEPTIC TANK
MIN 150OG .17 INVERT DROP GARB. GRINDER/t)0(2 comps +200)
10' TO FDN MANHOLE L,---� ELEV GW # COMPS. / GB
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLETq7 7 � - OUTLET97,&'O = '/ (2" OR .17 FT) TEE REQ'D?A/6
LEACHING
MIN 440 GPD? RESERVE AREA 4' FROM PRIMARY? — 2% SLOPE —
100, TO WETLANDSA� 100' TO WELLS 4' TO S.H.GW (5'>2M/IN)
20' TO FND & INTRCPTR DRAINS 400' TO SURFACE H20 SUPP
4' PERM. SOIL BELOW FACILITY MIN 12 " COVER FILL? '--(15'
BREAKOUT MET?
TRENCHtS
MIN 440 gpd SLOPE (min .005 or 6"/100 L--�SIDEWALL DIST. 3X EFF.
W OR D (MIN 61 L--- RESERVE BETWEEN TRENCHES? IN FILL? MUST
BE 10 MIJA& 4 11 PEA STONE? L--' VENT? (>3' COVER; LINES >SO')
BOT + SIDE X LDNG , 76 = TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright Q 1996 by S.L. Starr
'AORT11
Aroo A
CHU
Applican
Site Loca
Town of North Andover, Massachusetts
BOARD OF HEALTH
C�q
0
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Form No.2
I IReference Plans and Specs. n \A Y"
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
LOCATION:
NEW PLANS: ( YES
SEPTIC PLAIN SUBMITTALS
S60.00/Plan
REVISED PLANS: YES .$25.00/Plan
DATE:—
DESIGN ENGINEER:—&'�-L
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 16.1,
When the submission is all in place, route to the Health Secretary
Town of North Andover, Massachusetts Form No. 1
AORTH BOARD OF HEALTH
lB����
` APPLICATION FOR SITE, TESTING/INSPECTION
App|ica
SitoLmz
Engineer
t �ju dil�%
Test/inspectionTest/inspection Date andTi
CHAIRMAN, BOARD OF HEALTH
Fee. Test No.
S.S. Permit M ,VV]�' ��n j�. Dato________P|ho Permit No.
_ _ ______ _
MORTGAGE PLOT PLAN
LOT # 14 RALEIGH TAVERN LANE
(F,,V D) NORTH ANDOVER, MASSACHUSETTS
BUYER: LAURENCE S JUDITHJ. LYONS
tql 0
SCALE: 1" 40'
JUNE 27,1983 0 04
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43j69B SE
CYR ENUNEERING SERVICES INC.
300 CANAL STREET
LA'NRENCE,MASSACHUSETTS
V
Se7*,59'40'* w
(24.2e')
s
10.40
s .5,07*�47'57"W
REFER, TO N&R,D, PL* L3317
NOTE: THIS IS NOT A SURVEY AND IS TO BE USED FOR MORTGAGE
PURPOSES ONLY.
N.B.- DO NOT USE OFFSETS FOR ESTABLISHING LOT LINES FOR THE
ERECTION OF.FENCES, WALLS, HEDGI, ETC.
I HEREBY CERTIFY THAT THE BUILDING ON TitlS PROPERTY IS
LOCATED AS SHOWN ON PLAN AND COMPLIES WITH THE ZONING SET
BACK REQUIREMENTS OF THE TOWN OF NORTH ANDOVER.
I FURTHER CERTIFY THAT THE ABOVE PROPER:v ;S NOT LOCATED
IN A FLOOD PLAIN ZONE. I
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Perrdt 118
Lot 14 Raleigh Tavem
Curtis Dev Co
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit fora sewage disposal installation at
Lot lh Ra-leiLyh Tarern Rd - 0 1 will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inchest and will maintain a minimum grade of 196' until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of loop in size. A manhole (s) permitting easy cleaning
will be provided with� removable 'cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 200 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/81, to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average d . epth of trench shall not exceed 36 inches
No part of the installation will be less than 100 feet from any private water suppiy,
25,feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
Ifurther agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE 5/8/69
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE 5/8/69
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE Z-1 Z __
Signature of(��I;eZting Officer
Percolation Test 5 Min spil Clely -
Garbage Grinder
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
1. NAME (-Lx-,4t' COAD DATE k�kzlz- Ink
2. ADDRESS Lw LOT NO. L/ TEL.
3. NO. OF BEDROOMS DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
360
%J/
BOARD OF HEALTH OF NORTH ANDOVER) MASSACHUSETTS
NAME OF APPLICAN
LOCATION
SEWAGE DISPOSAL
n A MW
P I
L*
BUILDING: Dwelling L(, -Other
SYSTEM: New K Repair
GENERAL DESCRIPTION OF LAND_ U -t -y.
SUBSOIL: Clay��— Aavel Sand
PERCOLATION TEST minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK_ J& -b -V gallon capacity.
LEACH FIELD 2_e -
t) Jineal feet of drain pipe.
A 0
Milliam J. Drrl.scEll, Enginee'r�
Board of H
eal4h