HomeMy WebLinkAboutMiscellaneous - 27 BRADFORD STREET 4/30/2018Ln
A
Lot & Street Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: YES
Plan Approval: Date:
Designer:- -F.7
Conditions:
Water Supply: Town Well
Well Permit: Driller:
Well Tests: Chemical
Bacteria I
Bacteria 11
Plumbing Sign -Off:
Comments:
Form "U" Approval
Date Issued
Conditions:
Final Approval:
NO Permit#J22-y—
Approved by: 5,4,1z
Plan Date:
Date Approved
Date Approved
Date Approved
Wiring Sign -off:
Approval to Issue
By:_
All Permits Paid?
Well Construction Approval?
Septic System Construction Approval?
Certification?
Other?
Any Variance Needed?
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
YES NO
CY
NO
S
NO
NO
YES
NO
YES
NO
YES NO
SEPTIC SYSTEM INSTALLATION
CONDITIONS:
Is the installer licensed?
Type of Construction:
New Construction: Certified Plot Plan Review
Floor Plan Review
Conditions of Approval from Form U
Issuance of DWC permit:
DWC Permit Paid?
DWC Permit #., . Installer: -
Begin Inspection:
Excavation Inspection:
Needed:
Passed:—� , Q, -> By: '-� �
Construction Inspection:
Needed:
As Built Plan Satisfactory:
YES:
Approval of Backfill: Date:
M
Final Grading Approval: Date:_!�\�t�vi,- By:
45ii) NO
NEW EPAIR
YES
YES NO
N
YES r
,��-YES NO
Y ES) NO
Final Construction Approval: Date:. *(110-L- By: 01,11)
Certificate of Compliance: Approval: Date:.
1A
Applicant -
0
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No.3
DISPOSAL WORKS CONSTRUCTION PERMIT
V NAME ADDRF-55 TELEPHONE
Site Location— "� 7, \5/7
Permission is, hereby granted to Construct or Repair (ij--an—I'ndividual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
Fee
-4 _-'JA I
—CHAIRMAN, BOARD OF HEALTH
D.W.C. No._ -JR -J' -ZS_
BOARD OF HEALTH
NORTH ANDOVER, MA 01845
978-688-9540
APPLICATIONFOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:
CURRENT INSTALLER'S LICENSE#
LOCATION: _JQ
LICENSED INSTALLER:
SIGNATURE:
CHECK ONE:
REPAIR: X
TELEPHONE# -
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$160.00 Fee Attached?
Foundation As -Built?
Floor Plans?
Approval.
Administrative Use Only
Yes No
Yes No
Yes No
NOONAN & Mc DOWELL, INC.
25 Bridge Street, Suite 6, Billerica, MA 01821-1023
Voice (978) 667-9736 Fax (978) 671-9565
Email: nmPnetway.com
Date: January 17, 2002
Town of North Andover
ALf rA
Office of the Health Department P,0
Community Development and Services Division
27 Charles Street LUUL
North Andover, MA 0 1845
RE: Subsurface Sewage Disposal System
Plan Review, 1770/ 057A
27 Bradford Street
Assessors Map 61, Lot 35
Dear Members of the Board,
Please be advised that Noonan & McDowell, Inc. has reviewed the plan dated 12/12/01,
Revised 1/10/02 by: New England Engineering Services Inc. It is our opinion that the proposed
design will meet the requirements of Title 5 and the North Andover Board of Health "By -Laws"
if the following is addressed:
1.) Adjust bottom of field to highest water table in hill (92.2).
Respec t�!Yfly
John L. Noonan, P.L.S.-P.E.
G:office/fonns/27 Bradford.doc
Land Surveyors Civil Engineers Environmental Planners
NEW ENGLAND ENGINEERING SERVICES
lk . INC
January 30, 2002
Sandra Starr, Administrator
North Andover Health Department
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
Re: 27 Bradford Street, North Andover, Septic system design
Dear Sandra:
Enclosed are five copies of revised plans for the above referenced property. The
following changes have been made.
1. The system elevation has been raised to accommodate a higher water table.
If you have any questions regarding the information submitted, please do not hesitate to
contact this office.
Sincerely,
Benij;in C-Qg�/d, Jr., EIT
President
lj�
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 -,(978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
SEPTIC PLAN SUBMITTAL FORM
LOCATION: 2- -7 i2R f- 4-) �b R Q
NEW PLANS: YES $160.00/Plan
REVISED PLANS: (:ii) $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES ('--N4O'
DATE: 0'z
DESIGN ENGINEER:
r-!2-Tex-&Eat1�2 6-=
DATE TO CONSULTANT:
When the submission is all in place, route to the Health Secretary.
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Health Director
February 13, 2002
Ben Osgood, Jr.
New England Engineering Services, Inc.
60 8eechwood Drive
No. Andover, MA 0 1845
Re: 27 Bradford Street
Dear Ben:
Telephone (978) 688-9540
Fax (978) 688-9542
This is to notify you that the revised plans dated 1/29/02 for 27 Bradford Street have been
approved.
If you have any questions, please do not hesitate to call the Board of Health Office at
978-688-9540.
Sincerely,
1/' // JaA�
Sandra Starr, KS., C.H.O.
Health Director
cc: Stapleton
. file
SS/SMC
BOARD OF APPEALS 6'88-9541 BUILDING 688-9545 CONSERVATION 688-9530 INTURSE 688-9543 PLANNING 688-9535
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Public Health Director
Cease and Desist Order
March 12, 2002
J. Whyman Construction
451 Broadway
Lynnfield, MA 01940
Telephone (978) 688-9540
Fax (978) 688-9542
An inspection by North Andover Health Department personnel on March 12, 2002 found that
construction at 27 Bradford Street in North Andover had commenced without a permit having been
issued and without a plan signed by the Board of Health. This is a clear violation of Massachusetts Title 5
Regulations and a violation of North Andover Septic Regulations. All work at the aforementioned site
must cease and desist immediately and no work may commence until a permit is issued and a plan
stamped and signed by the board of Health is obtained.
If you have any questions, please call the Health Department at the phone number located below. Thank
you for your cooperation in this matter.
Sincerely, :�117
, � �'.: � �Zz! ��
Brian J. LaGrasse
Board of Health Inspector
cc: Board of Health
Sandra Starr, Health Director
File
BOARD OF APPEALS 688-9541 BUlLDING688-9545 CONSERVATION 688-9530 HEALTH688-9540 PLANNING 688-9535
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
March 20, 2002
J. Whyman Construction
John Whyrnaii
451 Broadway
Lptifield, MA 0 1940
Re: 27 Bradford St. N. Andover
Dear Mr. Whyman:
Telephone (978) 688-
9540
FAX (978) 688-9542
The North Andover Board of Health requests your presence at their next meeting on
March 28, 2002 to discuss your participation in the septic repair installation project at 27
Bradford Street, the alleged violations, and why the Board should not revoke your license to
operate in North Andover.
Please be present at 7:15 PM at 384 Osgood Street, North Andover at the Department of
Public Works. Failure to appear may result in an automatic revocation of your Disposal Works
Installer's License to operate. If this time is not convenient for you, please call the Health
Department at 978-688-9540 to place you earlier or later on the agenda.
If you have questions, please call the Health Department.
Yours truly, (for the Board)
Sandra Starr, R.S., C.H.O.
Public Health Director
Cc: BOH
File
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Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Public Health Director
March 29, 2002
J. Whyman Construction
John Whyman
451 Broadway
Lynnfield, MA 01940
Telephone (978) 688-9540
Fax (978) 688-9542
RE: Consultant Engineer Invoice for Additional Services at 27 Bradford Street
Dear Mr. Whyman:
This letter is to.inform you that our engineer ing consultant's additional time for two
bottom of bed inspections must be paid in full prior to the issuance of a Certificate of
Compliance. John Noonan of Noonan & McDowell, Inc. performed two bottom of bed
inspections due to excavation errors at $160.00 dollars each, totaling $320-00. These additional
costs must be submitted to the Board of Health as soon as possible for the projects closure.
Please make a special note that the Certificate of Compliance will not be issued until the fee has
been paid. Thank you for your cooperation.
Sincerely,
Brian J. LaGra.sse
Health Inspector
cc: Board of Health
Sandra Starr, Health Director
File
Homeowners' representative,
Jonathan Stapleton
3411, Floor
399 Park Ave
New York, NY 10022-4690
/0
BOARD OF APPEALS 689-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH688-9540 PLANNING 688-9535
NOONAN & Mc DOWELL, INC. -
25 Bridge Street, Suite 6, Billerica, MA 01821-1023
Voice (978) 667-9736 Fax (978) 671-9565
Email: nm@netway-com
Date -Z,
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, MA 01845
RE: Subsurface Sewage Disposal System
Plan Review, 1770/.,
— ee__7
Assessors Map 6 1 , Lot
Dear Members of the Board,
Please be advised that Noonan McDowell, Inc. has reviewed the plan dated 17�11_1_lv
It is our opinion that t9e proposed design will meet the requirements of Title 5 and the North
Andover Board of Health "By -Laws" if the following is addressed:
.5 7— C7
77—
Respectfully,
John L. Noonan, P.L.S.-P.E.
G:office/forms/tonarev
Land Surveyors. Civil Engineers Environmental Planners
SEPTIC PLAN SUBMITTAL FORM
LOCATION:
NEW PLANS: $160.00/Plan
REVISED PLANS: YES $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: S NO
DATE:
DESIGNENGINEER: t,)c-;vv -Pev&jA-tv,3 F'-) C' k'v ('
DATE TO CONSULTANT:
When the submission is all in place, route to the Health Secretary.
-11
NEW ENGLAND ENGINEERING SERVICES
lk I INC
December 21, 2001
Sandra Starr, Administrator
North Andover Health Department
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
Re: 27 Bradford Street, North Andover, Septic system design
Dear Sandra:
Enclosed are the following documents in reference to the above referenced property.
1. 5 sets of septic system design plans.
2. Soil evaluator sheets.
3. Application for approval.
4. Check to cover the approval fee.
If you have any questions regarding the information submitted, please do not hesitate to
contact this office.
Sincerely,
Bka4-2n C OC-o-4rJ)r, EIT
President
I/
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
NEW ENGLAND ENGINEERING SERVICES
INC
January 14, 2001
John Noonan
Noonan and McDowell, Inc.
25 Bridge Street
Billerica, MA 01821
Re: 27 Bradford Street, North Andover
Dear John:
Enclosed are revised plans for the above referenced property. The test pit locations have
been swapped and the system location moved to be over the appropriate pit.
If you have any questions please do not hesitate to call.
Sincerely,
��(fo :7,
Benjamin C. Osg� /od, Jr., EIT
President
60 BEECHWOOD DRIVE - NORTH ANDO�ER MA 01845 - (978) 686-1768 - (888) 359-764§ - FAX (978) 685-1099
9
Town of North Andover, Massachusetts Form No. 2
oq j40R'r#j BOARD OF HEALTH
41
DESIGN APPROVAL FOR
CH SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant
Test No.
ion
Site Locat
Reference Plans and Specs..dd�--
A, _:�-14 - �- - —
ENGINEER DESIGN
LY DATE
Permission is granted for an individual soil absorption sewag
e disposal system to be installed
in Accordance with regulations of Board of Health.
�M �
cHAIRMAN, BOARD OF HEA�TH
Site System Permit No. -//!2/---
Town of North Andover, Massachusetts Form No. 1
0i VAORT)i BOARD OF HEALTH
'& -'J�Ea .6 - C) C- t
0 0
APPLICATION FOR SITE TESTING/INSPECTION
rED
CH0
Applicant Y7 9 V4 -s
NAME ADDRESS TELEPHONE
Site Location ;-I Arj-�-'j s;-+
,/VZD711 ? /ayj d I 'va 97o' -616-171A0
Engineer. S�E�'Jiceq' tyle, (z) 0 13eeJ waoJ Dr i
NAME ADDRESS fff7dol)er TELEPHONE
Test/I nspection Date and Time
CHAI RMAN, BOARD OF HEALTH
Fee Test No. mc;�46
S.S. Permit No.—D.W.C. No.______C.C. Date—Plbg. Permit No.
I
0
BOARD OF HEALTH
NORTH ANDOVER, MA 01845
978-688-9540
OCT 2 2 200T
APPLICATION FOR SOIL TESTS
DATE:
MAP & PARCEL:
LOCATION OF SOIL TESTS: z2 -1 re
0 WNER: 0 b t�j TEL. NO.: 7S - G er--
ADDRESS: _,�Z 7 A/c, tL rg j N,&) yt)
ENGINEER: F- TEL. NO.:
WO 6.- -17
CERTIFIED SOIL EVALUATOR: fz,CR 0 -
Intended Use of Land: Residential Subdivision Single Family Home Commercial
Is This:
Repair Testing:
Undeveloped lot testing:
In the Lake Cochichewick Watershed? Yes No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
1. Proof of land ownership (Tax bill, or letter from owner permitting test)
2. Plot plan & Location of Testing
3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area.' Fee of $200.00 per lot for repairs o
upgrades. (Jf time is not critical, fee for repairs is $75.00)
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers cap. design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the
BOH representative.
5. Full payment wilI be required for a1l additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than I "A 00') shal] be submitted to the Board
of Health showing the location of aH tests (including aborted tests)
7. Within 60 days of testing soil evaluation forms shaU be submitted.
Please Do Not Write Below This Line
N.A. Conservation Conunission Approval:.
Date Received: /,woo/ Check Amount:
Check Date: & f
VY1 -;r-Y /NA b
FORM 11 - SOIL EVALUATOR FORM
Page I of 3
No. . pa, —5 , 2— Date:
Commonwealth of Massachusetts -
Massachusetts
Soil Suitabilio Assessment -Lor On-site Sewage Disposal
Performed By: ......... Date:
Witnessed By:
L=auon Addr"s or .0-,.,'. N.-. VplWr,
L.V I Aftess. and Or�
Telephone 1 7
/V/
New construction 1:1 Repair
Office Review
Published Soil Survey Available: No El Yes
Year Published .............. Publication Scale Soil Map Unit
Drainage Class Soil Limitations
Surficial Geologic Report Available: No El Yes F
Year Published Publication Scale
Geologic Material (Map, Unit) ......... I .................. ... .............. - ...... .......... ...
Landform........................... ... ................................................ ...................... ...........
Flood Insurance Rate Map:
Above 500 year flood boundary No E]Yes 191
Within 500 year flood boundary No E]Yes 0
Within 100 year flood boundary No E]Yes R
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS): Month
Range :Above Normal E]Normal Ehelc,v Normal
Other References Reviewed: 1 2.0
DEP APPROVFD FORM - 12/07/95
Location Address or Lot i�o.
FORM 11 - SOIL EVALUATOR FOWN1
Page 2 of 3
On-site Review
Deep Hole Number D ate: Time:
Location (ide if on site plan)
9-�i y
Land Use Slope M Surface Stones
Vegetation
Landform
Position on landscape (sketch on the back)
Dista . nces from: t Drainage way f eet
Open Water Body fee
Possible Wet Area feet Property Line feet
Drinking Water Well feet Other
Weather��V--!57'#
DEEP OBSERVATION HOLE LOG*
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, 1/0
Gravel)
4111r,
it
7
jz>-V1A,A-r-
- mimmum vr Z rIULrO rlC�UUIFILU 1-
I
Parent Material (geologic) 6? r171 -ell DepthtoBedrock:
Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:
Estimated Seasonal High Ground Water : ac'52 —
DEP APPROVED FORAI - 12/07195
Location Address or Lot No.
FOWN1 11 - SOIL EVALUATOP, FOIni
Pa g c 2 () f 3
On-site Review
Deep Hole Number Date:. 1111:�FI—Vl Time:/d!51— Weather,/ 1-V/1 -Z� 7- --5
11"P Location (identify on site plan) ".- 111!��.-.---. .-Z
Land Use Slope (%) / Surface Stones
Vegetation <:; 5 �' or --5
Lanclform4m"��0'41-�'*w �/X/
Position on landscape (sketch on the back)
Distances from:
Open Water Bocly/-41110-1*-'�' feet
Possible Wet Area :>/,0147 feet
Drinking Water Weli,, feet
-12 -1�
Drainage way 140
feet
Property Line f eet
Other
DEEP OBSERVATION HOLE LOG*
Depth from
Surface (inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency,
Gravel)
%C
it
4
c.
MINIMUM
OF 2 HOLES REQUIRED
AT EVERY PROPOSED DISPOSAL
AREA
Parent Material (geologic) DepthtoBedrock:
Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:
Estimated Seasonal High Ground Water:
DEP APPROVED FO"t - 12/07/95
FORM 12 - PERCOLATION TEST
7
Location Address or Lot No. Z- 7 F
COMMONWEALTH OF MASSACHUSETTS
/i �' , Massachusetts
Percolation Test *
Date:
5-1a Time:,
0 Observation Hole #
bse rva tio n Hole #
De th 0 f Perc
P
S t t
Start Pre-soak
Pre -so ak
End Pre-soak
Time at 12"
0 z 5
Time at 9,-
—
g�r
Time at 6"
Time (9"-6"
Rate Min./inch
Minimum of 1 percolation test must be performed in
reserve area. both the primary area AND
Site Passed Pl'_�Site Failed
................ ..................................................................... .............................................. . .......... .........
Performed By:
.... ...... ....... (2 _04;� 51C,
witnessed By:
Comments:
..... ......
DEP APPROVED pORj4 12107/9S
FORM I I -SOIL EVALUATOR FOR Nj
Page 2 of 3
C/O 5-7,
Location Address or Lot i -4o. —Z' 7
On-site Review
Deep Hole Number Date: Time: / a A-1'7 Weather
Location (identify on site plan)
Land Use
SlopeM Surface Stones
Vigetation
Landform
Position on landscape (sketch on the I back) W C; r/ V
Distances from: F�Al
Open Water Body feet Drainage way > feet
P _5-0 4
ossible Wet Area 012 feet Property Line feet
Drinking Water Well
feet Other
DEEP OBSERVATION HOLE LOG
Depth from
Surface tinctwes)
Soil Horizon
Soil Texture
IUSDA)
Soil Color
tMunsell)
sod
Mottling
Other
(Structwe. Stones. %ulders. Consistency. %
Graven
17/Z_
r-,5
t1i
15-- 7
At
r
72 - 106
Z_
V F�5
5-"-
(2 7 Z_
PgjP11_e=�1 12
UtA
OF -2 Kdrn,immi
Parent Material (geoiagic) (? U r e, V rj 0*0=0 , 'cl:
Depth to Groundwei, Standing Water inthes Hole: AI Q - Weeping from Pit Face: .10V 4_7
Es'bmatbd Seasonal High Ground Water: so
DEF APPROVED FORM - UWIPS
Location Address or Lot v4o
FORM 11 - SOIL EVALUATOR FORNI
Pa. -
,,c 2 of 3
1-7 -
'701 -7
2. -7 5 7—
/V vzt:s��
On-site Review
Deep Hole Number Dale:_e�/j 5/0 Time: -1-12 -Weather
Location fiden'tify on site plan)
Land Use Z_ Slope M Surface Stones
V6getation
Landform
Position on,landscape (sketch on the back)
Distances from:
Open Water Bo - dy feet Drainage way '>/00 feet
Possible Wet Area '7 /0 0 feet - Property Line feet
Drinking Water Well 7 -0 -*V feet 'Other
Alcemwp r;pvve,"`�
42 DEEP OBSERVATION HLOLE LOG*
Depth from
Surface (inches)
Soil Horizon
Soil Texture
4USDA)
Soil Color
tMunsell)
Soil
Mottling
other
(Structunt. Stones. Boulders. Consistency. %
Graven
0— _Z 0-
A
Pyet 1/3,
-)7
L
-3 7 10
75- At
-�o
15-Y
wig/ eq lva
-,04er- 54-
17-37-,
8' -2
?
T
:)LE!. REQUIRM
AT ;;V 1;AYPAnPnr�MrS11!3M11
X152EX
Parent Material (geologic) 67v7zv .1 Depe"I'l * 'Cl: "7
Depth to Groundwaier-
Standing Water in the Hole: Weeping from Pit Face:
Estimated Seasonal High iGroxd Water: gwvx
IDEP APPRONM) FORM - UM7115 TF AK tf;4 21
7 5't= T—e
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No.
Determination for Seasonal. High Water Table
Method Used:
El Depth observed standing in observation hole
0 Depth weeping from side of observation hole
El Depth to soil mottles ... . ..... ... � .'<- ... � inches
El Ground water adjustment ................... feet
Index Well Number ........ .........
Adjustment factor ...... ............
Reading Date ............ .....
inches
inches
Index well level
Adjusted ground water level .... -- .. ... ..... . ... - -
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist I n a1Jjareas
observed throughout the area proposed for the soil absorption system? --YZ-5.51
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (date) I have passed the soil evaluator examination
approved by the I)dpbr'tment of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CIVIR 15.017.
Signature
WDEP APPROVED FORM - 12/07/95
Commonwealth of Massachusetts
5�.O,ffici,a�l';I,nspoctio,n'.�Fo�rm
Sub6tirrice SdWage �di tjhta
ili�osm S "N' , i6 V,4
ysitiih.fohn;-�, bi r
19 - r . . m
y Assess enti;
27 Bradfoird,Stredf
Property Ad s
David R6110
Owner
0wner's Name,
information is
required for Ndirth.Ahdover
MA. 01845 10/10/09
eve age. City/Tdwn
ry p stitd �ip Codd
Date of Indpection
Inspectfon'resAs must be submitted on this"f6r"
m.-Ihsoftilibn forms: may not be altered In any
way. -0I6aie-sS4e'cornpIet0heqd che�kfist atthe en4.bfthe form .1, .
Impo"aft
A. General Infortnati6n
When filling out
forms on the
computer, use 1'. Insp`edior:
only the tab key
to move your Benjamin C., Osgood, Jr._ OCT 2 0 2009
cursor - do not
. Name'& lMpdctor' �l
use the return
'NORTH ANDOVER
TOWN OF
key. none HEALTH DEPARTMENT
Company Name
224 High Street, 4t I
CompanyAddress
Newburyport MA "01950
Cityrrown state
Zip Code
978-255-2261 .870
Telephone Number License Number
B. Certificatio'n.
I certify that I have personally inspected the sewage disposal system it 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 experienc6 in the proper function and maintenance of on site
sewage disposal systems. Farn a DEP approved system inspector pursuant to Section 15.340 of
Title 6 (310 CIV111,116.000). The system-
�dss'e`s Conditionally Pa'�ses Fails
El Needs-FuTthet Evaluation 'by the Local Ap'proV'.-, g Autfiont
in y
I oti 0/09
is.
r
Insp-ecto ignatu Date
The system inspe6tor sfi�611 submit,ja copy of this i6spection reportlo the Approving Authority (Board
of Health or DEP) Wfthin'30 days ofcOmpleting this�,inspection. If the system,is a shared system or
hai'a desi6n.�ow of i&000, gpd-o
r §reater, the insp6cto� and the system owner shall submit the
report to the appropriafe ' regional office of the DER The original should'be sent to the sy9tern owner
and copies sent to the. buy6r,,if applic'aWe, r6nd- the approving auth9rity.
****This report,only desckbes conditions at the time of inspection and under the conditions of use
aftheit time.,T.his insipection: does; not address how the
sys�em will perform in the future under
the same or different conpl6ns;4, use.,
M
Owner
information is
required for
every page.
corinimohwiilth- of Maissachus6tbs'
TWO&,offic"lall
nspec. o .:'prn
Subsurface Sewage 6W al System -Form-. Ndt for Volu . nta�y Agses§men,
POP
27 Bradford street
Property Addrik"
David,.Rollo
Owrief s Name
North Andover'
-MA;
:01845 i 10/10/09
City/ToWn state Date of Inspection
Zip Cddc
B. Certificanion (cont.)
In spepti.on Summary: Check; A, BiC, 0 or E always complete all of SeUion D
A) System Passes-
I'have not found any inf6rmatiog , Which ind i6at6s thaiit!ah . y' of the failure criteria described
in -31 Om CMR 15.30 oi%inll 310 C MR 15.304 exist Any failure criteria not evaluated are
indicated below. -
Comments:
13) System Conditionally Passes:
Qne or more system -components as described in the "Conditional Pass" section need to be
replaced oriepiirk The sy t' din
s en)� upon r pproved by
pletion of the'replacement or repair, as a
the- Board of -Health, Will pass.
Check the box for"Yes%`nor or "n6t deb�rrninad".(Y, N, N t' D) for the following statements. If "not
determined," plea"se explain.
The septic tank is. 'metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsoA, ex.6ibits substantial infiltration or eAltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with'a complying septic tank as approved by the
Bbar&of Health.
A �ne�i�-iepii"c'tan'k'will�"�ats Ape ction if i6sstr'uc`turait� sound, not leaking and if a �Certificate of
Complian" ce indicating th . at the tanR is''Ies's r than 20 years old is, available.
Y'� ET N El ND (Explaih'eelowl'.
A 'I
C m C
o' mon*ealth 'of MAsia busefts
Title cia ns- e ion orm
Subsurface' Sewa w0iispoW System Form N6t for Voluntary Assessments
9
27 Bradford Street
Proper,ty Address,*
David -Rollo
Owner Owners'Narhe
information is
required for North Andover -MA 01846 10/10/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
8� System d9ndM6nahy,'P;6i64 (Porit)
Ob�efrvation,ofse`wage- backuo. or breaf,kbut. or high static watef level in the distribution box due
to broken 0 ' ?
rob tr cte
s. u,,,,.. d pipe(s) or due ta a beoken, settled or un6en distributiori box. System will
p as . s insp6ction.if (with approval of Board of Health):
El lb�oken pipe(s) are replaced r-1 Y El N: Ell ND (Explain below):
El obstruction is removed. Y F1 N Ell ND (Explain below):
'dist6buti6ri, box it lev'ded or' 'rer)[aced E]; Y f] N El� ND (Explain below):
El TM system required Ournpingim'6re thirl, 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with apprdval of the Board of Health):
El broken pip4(s) are replaced El Y D N El ND (Explain below):
'obstruction is removed El Y El N El, ND (Explain below):
C) Further Evaluation is,,Required by the, Board of 1-16alth:
El. Conditions existwhich, require further Ovaluation. bythe Board of Health in order to determine if
the system - isfailind to �r�tect poPlic-hea.1th, . 9.afeN or th6brivironment,
I., System will pass unless Boae&& Health determines In accordance with 310 CMR
16.303(i)(b).that the systierh is not fundtioning in amanner which will protect public health,
safety and the environment:
Cesspool or privy is within 50 feet of 'a sUrface Water
b
0. Cesspool ri 'is' in 50 feet of 6
P,vy With
a ordering vegetated wetland or a salt marsh
Owner
information is
required for
every page-
Common*ealth of Massac,hluseds
Titlel offiOial;,j %,diflon.-Form
Subsu, 6e SLIW496 01spo'sail'Sys tern 11�brm Not fo rVold I ntary Assessments
2� Bradlord Street
Propi* Address
David Rollo
Owners Name
North Andover MA .01845
10/10/09
City/Towh a
�state! Zip Cod i Date of Inspection
B. Cerfifice'tion t)
2. System will fall unless the Boaird.of Health (and, Public Water Supplier, If any)
-determines that the systern'lis functioning In a manner that protects the public health,
safety and environment:
The'system has a septic tank. and soil absorptign system (SAS) and the SAS is within
100 feet of a surface water supply -or tributary to a surf6pe water �u *
s pply.
E] 'The system has a.�septic tankand SAS and the SAS is within a Zone 1 of a public water
supply.
FT. � The system has a septictank and SAS and the SAS iswithin 5:0 feet of a private water
supply weR.
The system has a septic tank and SAS and the SAS is less than I 00'feet but 50 feet or
mor6f.rom a. private water supply well".
Method used to determine distance-.'
This system p
pass.es if the'W611,water ' analysi�0,' ieff6rmed at a DEP certified laboratory, for coliform
re§ence of ammonia nitrogen and nitrate nitrogen is equal to or
bacteria indicates absent and the �P � �
less than 6* Opm, 'prcivided t�hitt no other fail'ture -criteria are triggered. A copy of the analysis must be
attached to-ihis form.
3. Other:
D) System FaildreCriteria Applicable to-All.,Systems:
You must ifi,dicaie "Yes!' or "No" to each"of the following for all Inspections:
Yes No
Backup of sew"a6e into facility or system component due to overloaded or
El 0 clogged SAS or cesspool I
Ei ia D.ischar6e -or pp.ndi.ng, of effluent to the surface of the ground or surface waters
due tq an dVerl6ad,6d �o� clo66od SAS( 'orcesspool
Static,liobid leVel'in:th6fdi9tr`ib6tibn box ibove outlet invert due to an overloaded
or c oggdd, S 6r'ceSSD00l
Liquid,depth in cesspool is less than 6" below invert or available volume is less
%than%dayf1pw
E) Large Systems.; To be considered a largo system the system must serve a facility with a
desigmfl,pw of,10,000 g,pd to 15'000 gpd.
For lar& -systems, ypu must indicate either "yes" or "no" to each of the following, in addition to the
question si in Section''D.
Yes No
El 9 the system is within 400 feet of 6 surface drinking water supply
'the s�ys�em' is within 200 feet of a tributary to a surface drinking water supply
-El' Z
the 9
ysterhJ& located, in 6 nitroge6l sensitive area (interim Wellhead Protection
Area " IWPA) or a mapped Z f
..,one: 11 o a public water supply well
If you have answered "yes" to any question in Se�tion E the system is considered a significant threat,
oranswered "yes" in Sebtion D abdive'the large system has failed. The owner or operator of any large
.system considered asignificant. threat under Section E or failed under Section D shall upgrade the
jsystem in accordance with 310 CMR 15. - 304. The system owner should contact the appropriate
regional office of the Department.
ComWonwealth of Massachu etts'
Title .5.
Official Insp elction Form
Subsurface Sewage Disposal System. Form Not for yoluntary AssesIsments
27 Bradford Street
Property Address,
David Rdllo-,'—�
Owner Owners Name
inforrnation is
77 --
required for North.Andov6r
Mk 01845 10/10/09
every page. City/T"n
State Zip Code Date of Inspection
B. C irtiflication (cont.)
Yes
No
R equired pumping'! more.thari 4 times in..'the last year NOT due to clogged or
obstrudt6d pipe(s). Numbir-of tirhais-pum'ped:
F1
por-tion'of'the ces' ' 10
9 Any SAS sp' ol or priv'y is below high ground water elevation.
El
0 Any portion ofcesspool or privy is within 100 feet of a surface water supply or
tributary to a surfAce water supply.
Any portion of Ya cesspool or privy is within a Zone I of a public well.
Any''portion of -,a cesspool or privy is within 50'feait of a private water supply well.
Any portion7of 6 cesspbol or privy is* -less than 100' feet but greater than 50 feet
from,� a private water supply wd with no acceptable waiter quality analysis. IThis
system passes if the well water analysis, performed at a DEP certified
laboratory,,for fecal collform bacteria Indicates absent and the presence
of arnmonialnitfogen 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 4hain of custody' must be attached to this form.)
The system is a cesspool servinga facility with a design flow of 2000gpd-
10,000gpd.
The , system fails. I have determined thAtone or more of, the above failure
criteria exist as -described in 310 QMR 115,303, therefore the system fails. The
systern'owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems.; To be considered a largo system the system must serve a facility with a
desigmfl,pw of,10,000 g,pd to 15'000 gpd.
For lar& -systems, ypu must indicate either "yes" or "no" to each of the following, in addition to the
question si in Section''D.
Yes No
El 9 the system is within 400 feet of 6 surface drinking water supply
'the s�ys�em' is within 200 feet of a tributary to a surface drinking water supply
-El' Z
the 9
ysterhJ& located, in 6 nitroge6l sensitive area (interim Wellhead Protection
Area " IWPA) or a mapped Z f
..,one: 11 o a public water supply well
If you have answered "yes" to any question in Se�tion E the system is considered a significant threat,
oranswered "yes" in Sebtion D abdive'the large system has failed. The owner or operator of any large
.system considered asignificant. threat under Section E or failed under Section D shall upgrade the
jsystem in accordance with 310 CMR 15. - 304. The system owner should contact the appropriate
regional office of the Department.
Cofift"'onwealth of Massachuseils
Title 5 -Official, Inspection Form
Subsurface Seftge.P�sp a
I SVstem Form -.,Not for Voluntary Assessments
, -7
27 Bradford Street,
Propert§ Address
David Rollo
Owner Owners Name.
information is
required for North Mdover MA -01845 10/10/09
every page. Cityrrown State 7jp Code Date of inspection
A
C.-ZhOdkiisi
Check if the following have been done. You must indicate -"yes'� or "no" as to each of the following:
Yes No
Pumping information was -provided by owner, occupant, or Board of Health
El 0 Were My of the,systern components pumped out in the previous two weeks?
;lz 0 Has the system redeiv6d normal flowsiin the previous two week period?
El 9- Have large voluMes of.'water been introduced to the system recently or as part of
this inspection?'
Were as 6Uiltplans of th I e system obtained and examined? (If they were not
avail ' able note as N/A)
ED El Was the facility or dwelling inspected for signs of sewage back up?
S' El W.1sthe site in�oebtedtfbr signs of b�4ak out!
W�4 all system components, excIudirig the SAS, located on site?
Were the septic tank manholes. uncovered, opened, and the interior of the tank
inspected forthe condition' of the baffles or, tees,.material of construction,
'dimensions, depth of liquid, depth of sludge and depth of scum?
Was thelacility owner (and occupants if different from owner) provided with
information on the proper maintenartce of subsurface sewage disposal systems?
Ne a* and location; of the Solli ikbi&ption System (SAS) on the site has
been deteimmibedbased�on:
Existing information. For 6xamole,'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. gyst6m Ifform'sition
Residential Flow Conditions:
4 3
Number of bedro6ms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x of bedrooms): 440
Common,wealth of Massachusetts
Title �5 "Official.] -'s
n pedtio� Form
n.
Subsurface tewage-Disiposal, yetern Form -Not fbrVoluntdryAssessments;
27 Bradford Street
Property Address
David Rollo
Owner
information is
Owners Name
required for
North Andover - 10/10/09
MA 01845
every page.
City/Town statW7� rip Cade Date of Inspection
D. y 3 t6i mi I n f or"m a t i o':, ni
DescOption:
Number of current residents:
2
Does residence have a garbage grinder?k'I
El
Yes 0 No
Is laundry on a §eparatesewage system? [if yes separate inspection required]
El
Yes 0 No
Laundry system -inspected?*
El
Yes 0 No
Seasonaluse�
0
Yes Z No
Water meter readings, if available (last 2 years usage' (gpd))*
Detail:
Sump pump?
Yes No
Last'date of occupancy:
current
Date
Comme'"rciallindustridl Flow Conditions:
Type of Establishment
Design flo* (based on 310 CIVIR 15.203):�
Gallons per day (gpd)
Basis of design flow (seats1persons/sq.f(.,'etc.):
Grease trappr6sent ,
El
Yes El No
Industria wast0h6ldingt6n4reseni!
Yes n No
Non,sdnitary waste dischaeged to the'Title 5 system?
El
Yes [_1 No
Water meter readings, if'available:
ommonwealth of Massa'chuiitts
Title 5 -Official Inspectioin- Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Bradford Street,,
Property Address
David.Roilo'
Owner Owners Name
information is
requiredfor North Andover
MA 01845, 10/10/09
every page. City/Town state ?ip Code. Date of Inspection
D. System friformit-7io-n (coint)
Last date of occupAncy/Use,.
Date,
Other (descdb6 bel
qw)
PUMIJIng Records:
Source of information:
Genera!, Information
Spring 2600 perowner
Was system pumped as part of the inspection? Yes No
If yes, volu meptkmped:��"
gailons
How was quantity Ou mped deierminb
Reason for pumpin,g:
Type of System:
Septictank, distribution bbx,. soil absorption system
'F1
'§nbIe'cd§ipd6I
El Overflow cesspool
Orivy
El 'Shared- syst4m (yes or no) -(if yes, attach previous inspection records, if any)
El., Innovati46/AItern6tiVd ' techhol6gy� Attach a copy of the current operation and
miinienah66 contract (to be obtain6d fforn system owner) and a copy of latest
inspection bf the I/A system -by system Operator under contract
El Tight tank. Attach a copy of the� DEP approval.
El Other (describe):
Comnionwea'lth of Ma6sachusetti
Title. 5 OffidaU Ins edtidnform
-P.
Subsurface Sewage Disposiallsystem Form Not fbi Voluntary Assessments
27 Bradford Street
Property Address
David R6olo
Owner Owners Naine
inforrnation is
required for North Andover MA 01845 10/10/09
every page. Cfty/Tcw� Stife� ZiO Pode,
Date of Inspection
D. gykft m" thfor-Miati;
1160 (pont.)".
Approximate age of all* components, date installed (if known) and source of information:
Built 2002 per as built drawings
Were'sowage odors detected when arriving at the siteT El Yes 0 No
Building Se*6r (locate o6 site �plan).
1.51
Depth below-9rdft
feet
Matedil of constr
uction*
El castiron 0 40 PVC E]other (explain):
N/A
Distance frorp private Water, supply,, well or suction line.
feet
Comments (on condition of joints,'V6;h!tifig, evidence of 1e'akage, etc.):
Pipe new in basement
Septic Tank.(16cate on sitdl plan):
Depth below grade: 5
feet
Matedal of construction:
E concrete El metal [I fiberglass El polyethylene other (explain)
?
if tank is metal, list age:
years
Is age confirmed by a Certificate of qpmpliance? (qttach a copy of certificate) Yes E] No
1500 Gallons
Dimerisidnis:
lit
Sludge, depth:
Cominopw6alth of Massachui;etts
Title 5 Official Inspe n'r
ctio' orm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
27. Bradford Street
Property Address`
David Rollo
Owner Owners Name
information is
required for Nortft Andover MA� 0 1 k5 10/10/09
every page. Cityfrqwn
State Zip Code Date of Inspection
D. Spstem'Infdrimation (coint)
Septic Tank' (to'nt.)
Distan'de.torih to f 3011
p,o sludge-tobottom� of outlet tee 6r baffle
Scum thickn6ss'
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 141.
How were dimensions d6termin4d? Measure Stick
Comments (on pumping'recommendations, inletand outlet tee or baffle condition, structural integrity,
liquid levels as related to:outl6finveM evidence of leakage, etc.):
ank in good condition. butl�t tee in good condition:
Grease Trap floca.te on site plan):
Depth below grade:
feet
Material of construction:'
El concrete metal El fib . erglass El polyethylene other (explain):
Dimensions:
S6um thickness
Distance from top of scum to top'of outlet- tde'or, baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of.last �p'umping:
Date
COMMOnWiDalth M
of assa6husefts
Title &'-Official Inspection Fo'
Subsurface Sewage Disposal System Form Not for Voluntary A-5sessments
27 Bradford 8;treet
Property Address
David -Rollo:
Owner Ownbe.s -Narrie
infon-nation is
required for North:Andbver
MA 01845 10/10/09
every page. Cityrrown, State Zip Code bate of Inspection
D. Systeminformatl dn,,(cont)
Comments (on pumping t66ommendations, inlet and outlet tee or baffle condition, structural integrity,
liquidlevels- is related to outlet invert, eViOehcL- of leakage "
etc.):
Tight o'e Holdifig Tank (tank mud- be pumped at time df inspection). (locate on site plan):
Depth below grade:
Material of constructiom,
El concrete [I metal El fiberglass El polyethylene El other (explain):
9
Dimensions:
Capacit�:
gallons
Design Flow:
ballons per day
Alarm present: F1 Yes F1 No
Alarm level: Aldrimin working orde
r: El Yes 0 No
Date of lagi pumping:
Date
Comments (condition of alarm and float switches, etc.):
Attach copyof current pumping contract (required). Is. copy'. attached.? El Yes El No
Commonwealth of Massachusetts
Title 5 Offic W.''Ift.
'Mectlow-Form
Subsurface Sd%Nage' Dliposal;SYstem Form -.-No"'tfor �oluniary Assessments
27 Bradford Street'
--------------
Property Address
David Rollo
Owner
Owiner's Name
information is
required for North Andover 01845 10/10/09
MA,
every page. City/ToWn 9, Code Date of Inspection
----------------
D. SyStem Infoftation' (coht.)
Distribution Box (if present must be opened) (locate on site plan):
0110
Depth of liquid level above outlet invert
Comments (note if, box is -.level and clistributionjo outlets.equal, any evidence of solids carryover, any
evidence of leakage -into or out of box, etc.): -
.Box in good condition. Distr6ution equal. No evidence of leakage in or out.
Pump Chamber (locate on site plan):
Pumps in working order: Yes n No
Alarms in working order;
El Yes 0 No
Comments (note.conditiomof'pump chamber, condition'.of pumps and appurtenances, etc.):
Soil Absorption.System (SAS).(Iocate'on site plan, excavation not required):
If SAS not located, explain why:
Commo'nweialth of Massachu-s'atts
Title ' 5 Official, Inspection, F0'rM
Subsurface Sewage Dispo'sal System Foffn - Not for Voluntary Assessmei
27 Bradf�rd Street
ProWr7t-y Address;
David Rollo
Owner
Owners Name ------- 7r
information is
required for North Andover
KIIA 61845 10/10/09
every page. Cityrrown
State Zip Code Date of Inspection
D. System.Infibrmation (cont.)
Type:,
leaching pits,,
number:
le"aching'chambets
number:
El leaching galleries number:
leaching trenches number, length:
15'x 60'
"'le'a6hing field.$i
number, dimensions:
pverflow cesspool number:
El inhovative/altemative system
Type/name of technology -
Comments note 6oriditibri. of soif, signs of hydraulic failure, level of ponding, damp. soil, condition of
vegetation, etc.),
.Area of leach field looks normal. No evidence. of ponding, damp soil, or unusual �Leqetation.
Cesspools'(cesspool must be:pumped as part of inspection) (locate on site plan):
Number and configuration
Dept� -top of liquid to inlet invert
Depth "of §olids. layer
Deptfi'of scum layer.;�.
Dimensions of cesspool -
Materials of construction
Indicati6n,,of gro'Undiiaier. in'fib,w- D Yes n No
Commonwealth of.Mass,adhusetts
Title Sloffid.iat.ln.s- ctidn"Form
PO
Subsurface Sewage 1131spbsill S
a. ysterh Form Not for Voluntary Assessments
27 bradford Street
Property Address
Owner David Rollo
Owners Name
Information is
.required for North Ajidove'r MA 01845 10/10/09
every page. Cityrrown State
Zip Code Date of Inspection
D. Sy, stem Infoirriatiph (pont.)
Comments (not6 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 vegetabon,
etc.):
Commonwealth of Massachusetts
Title 5�'Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
27 Bradford Street
Propert)�Address
Davidkollo
Owner
inf6rmation is owners Name
required fbr NoA Mdov e -r
MA. 01845 10/10/09
every page. Zii�f -r6=4
State Zip Code Date of Inspection
D. System Informati.g!n (Gont.).1
Sketch Of Sewage Disposal S vide aview of the sewage disposal system, including ties to
ysteM: Pro
at least two oerman6nit'r6fei-enice lind'marks" or be ithin 100 feet Locate
nchmarks. Locate all wells wi
where 'public water supply.enters t e:building. Check one of the boxes below:
hand -sketch in the area belo4.�
El drawing aftachedsepaf4tely
CU 5- rA 0 CC.$
I-TA43 W
?.'7.'?'
2-174911.
?21
I-DAbx
11
Z- DObx
?
common,wealth of Massa'chuse
Title 5 Offidia, I I I lnspectio6� Form
Subsurface Sewage bitposat System. Form Not for Voluntary Assessments
27 Bradford Street
Property Address
David Rollo
Owner
Owner's Name
information is
required for North -Andave i MA .,01845 10/10/09
every page. Cityrrown 77;
�Ip Code Date of inspection
D. System. Infbirmaiflo'n (coht.)
Site Exam:
Check Slope
Surface water
Check cellar
Shallow.wells',
Estimated depth to high ground water.. 4
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from. system design, plains on record
1-29-02
If checked, dat6:.of design plan reviewed-,
Date
El Observed site (ab�fting property/pbservation hole within 150 feet of SAS)
checked with local goard of Health - explain:
Checked with local e
xcmtors, installers -
(attach documentation)
Acce'ss6d USGS datat�se;- explain:
usgs maps
You must describe how you established the high ground water elevation:
_��ystem constructed 4 feeti'bove seasonal high, ground'water.
Before filing this Inspection
Report, please see Report
Completeness Checklist on next page.
Commonwealth (it liftseachus'
etts
Title;5 "Official Inspection Form
Subsurface, Sewage Disposal,System Fo I - N for Voluntary Assessments
rrn ot
27 Bradford Street
Pmparty Address
David Rollo
Owner
owners Name
information is
required fbr North Andover
MA .01845 10/10/09
every page. Cfty/Town State iliFf--ode biteo—flnspe—ct�ion
E. Report Completeness Checklist
N Inspection Summary: A, B, C,'D; or E, checked
Inspection Summary D (Systerh' Failure Criteria'Appiicable to All Systems) completed
System Information — Estimated depth to high qrouhdwpter
Sketch of Sewage Disposal System
either drawn on page 15 or attached in separate file
NEW ENGLAND ENGINEERING SERVICES
INC
RECEIVED
November 21, 2005
NOV 2 3 2005
TOWN gHNDORTAH ANDOVER
HEALT EP RTMENT
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
RE: TITLE V REPORT: RE: 27 Bradford Street No. Andover, MA
Dear Ms. Sawyer:
Enclosed is a Title 5 Report for the above referenced property. The system Passes the
Title 5 inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
Be C. Osgood, Jr.
Certified Title 5 Inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
I Of 11
I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 27 Btafford Street North Andover, MA 0 1845
Owner's Name: David Rollow
Owner's Address: 27 Bradford Street North Andover, MA 0 1845
Date of Inspection: 11/17/05
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 60 Beechwood Drive North Andover, MA 0 1845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CMR 15.000). The system:
LZPasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority,
Fails
Inspector's Signature:
The system inspection 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does
not address how the system will perform in the future under the same or different conditions of use.
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
O*ner's Name: David Rollow
Date of Inspection: 11/17/05
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
�)E5 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:
I-V C) One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,
upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (YNND) in the for the following statements. If "not determine&' please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a
complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the
tank is less than 20 years old is available.
ND explain:
of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if
Wt—happroval of the Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
ND explain-
3 6f IJ OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner'sName: David Rollow
Date of Inspection: 11/17/05
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require ftuther evaluation by the Board of Health in order to determine if the system is failing to protect
public health, safay or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMA 15-303(l)(b) that the system is
not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
- The system has a septic tank and (SAS) Soil Absorption System and the (SAS) and the SAS is within 100
feet of a surface water supply or tributary to a surface water supply.
- The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and the SAS is within 50 feet of a private water supply well.
_71be system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well". Method used to determine distance
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organize compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner's Name: David Rollow
Date of Inspection: 11/17/05
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
V' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
V Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or
cesspool.
V Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
,,/ Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 day flow
V 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.
t/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
/VD (Yes/No) The system fail& I have determined that one or more of the above failure criteria exist as described in
3 10 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Urge Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
YOU ust dicate either "yes" or "no" to each of the following:
(The followmg - ia apply to large systems in addition to the criteria above)
Yes No
The system is within 40 of a surface dri�nking water s
The system is within 20:0 feet of a tnibu c
oa ace �drhliking water supply
The system is located in a
of a public water supply m
area (Inte-rim_Wellhead Protection Area - IWPA) or a mapped Zone Il
If you answered "yes" to any qyestio-n in Section E the system is considered a significant thr-bator answered "yes" in Section D above
the large system has fai -The owner or operator of any large system considered a significant thir"der Section E or failed under
Section D s,h� grade th'e system in accordance with 3 10 CMR 15.304. The system owner should confiid the appropriate regional
office of Se--Det;a�tment.
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner'sName: David Rollow
Date of Inspection: 11/17/05
Check if the foll6wine have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant or Board of Health
Were any of the system components pumped out m the previous two weeks-?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of an inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
V11 Was the site inspected for sign of break out?
1.1/ Were all system components, excluding the SAS, located on site?
Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
IMe size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
Existing information. For example, a plan at the Board of Health.
_Az� Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) P 10 CMR 15.302(3)(b)]
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner's Name: . David Rollow
Date of Inspection: 11/17/05
FLOW CONDITIONS
RESEDENTUL
Number of bedrooms (design) Number of bedrooms (actual).
DESIGN flow based in 3 10 CMR 15.203 for example: 110 gpd x # of bedrooms):
Number of current residents: 2 -
Does residence have a garbage grinder (yes or no): IV 0 .
Is laundry on a separate sewage system (yes or no): A/ 0 [if yes separate inspection required]
Laundry system inspected ( yes or no):
Seasonal use: (yes or no): ey o .
Water meter readings, if available Oast 2 years usage (gpd): J -o w /V
Sump Pump (yes or no): IV -0 .
Last date of occupancy__L�� r �r�—
CONEKERCIALIMUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft, etc
Grease trap present (yes or no):
Industrial waste holding tank present Cyes or no):
Non -sanitary waste discharged to the Tide 5 system (yes or no)
Water meter readings, if available:
I" date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: PC oki 1--lu- 1p 2 -�, (154.�j t -2c12_.
Was system pumped as part of the inspection (yes or no): '/t/40
If yes, volume pumped: lions - How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative(Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tight tank -Attached a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
q L L 10kqa C H
Weresewageodor detected wen arrivingat the site (yes orno): IV
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner's Name: David Rollow
Date of Inspection: 11/17/05
BUELDING SEWER (locate on site plan)
Depth below grade: i �,,>
Materials of construction: cast iron vl'40 PVC other (explain)
Distance from private water supply well c�`suction fine: & 14
Comments (on condition ofjoints, venting, evidence of leakaje, etc.):
AJ e �L/
SEPTIC TANK _(locate on site plan)
Depth below grade: 6,
Material of construction: X concrete metal —fiberglass_____polyethylene
Other (expla
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): _(attach a copy of certificate)
Dimens' ions: /,5�- -,,D &-Y+ LLIQ� AJ
Sludge depth: /- t
Distance from top of sludge to bottom of outlet tee or baffle: '26
Scum thickness: I- (
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle—
How were dimensions determined: o,4 C -,4s, -a 0 -S -I-) r 14,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
-TA--7 )A, I A-) (T -0,-j 0 IJ -T),3 A-1 Ce (-a( 0 c
AJ 1�) CF) 0 /1./,
GREASE TRAP 4- (locate on site plan)
Depth below grade:
Materials of construction:poncrete—metal —fiberalass _polyethylene other
(explain)
Dimensions:
Scum thickness: -
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of sludee to Ix oin of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner's Name: David Rollow
Date of Inspection: 11/17/05
TIGHT OR HOLDING TANK: -/ I A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials of constructiom, concrete metal fiberglass _polyethylene other
(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIEBUTIONBOX. (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 evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
-K I A�l e I e2 -
r— t, FI -19- A C)
PUMP CHAM.ER: A) 114 (locate on sire plan)
Pumps in working order (yes or no)______-.,
Alarms in working order (yes or no)_.
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner's Name: David Rollow
Date of Inspection: 11/17/05
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required
If SAS not located explain why
TYPE
leaching pits number
__leaching chambers, number
leaching galleries number
leaching trenches, number in length
jeaching fields, number, dimensions: F/ F(- C�' A5, -K
overflow cesspool, number:
innovativelaltemative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc)
A -P -6-A- , r, r- -rl el- D 1-- 0 () V, -5 ,-vo a^.iri-c, A-/0 F �i , o C/,j e C- o F-
Poti ?t- G� I , p -S 0. L- . , C a- U"�J'/s '-� Ac- V e &- --D ') A-1,
CESSPOOLS: Aj /4- (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of Construction
Indication of groundwater inflow (yes or
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Material of construction:
Dimensions:
Depth of solids
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
16 of I I*
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner'sName: David Rollow
Date of Inspection: 11/17/05
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate
all wells within 100 feet. Locate where public water supply enters the building.
It 6f � I'l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 Bradford Street North Andover, MA 0 1845
Owner's Name: David Rollow
Date of Inspection: 11/17/05
SM EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtamed from system design plans on record — If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
*-- 1 4 W'ST " y", �p e,5,% � - F a S, & F� o ,,—
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Staff
Public Health Director
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
05/17/02
This i ' s to certify that
the individual subsurface disposal system
constructed 0 or repaired (X)
by
Jon Whyman
at
27 Bradford Street
Telephone (978) 68&9540
Fax (978) 688-9542
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.
The Issuance of this certificate shall not be construed as a guarantee that the system will function
satisfactorily.
�lfrian J. LaGras-s-e--
North Andover Health Inspector
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
AS -BUILT CHECKLIST
LOT NUMBER, STRE ET NAME
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES 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 ELEVA TION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
ORIGINAL STAMP & SIGNATURE
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
v1 LOCATION & ELEVATIONS OF BENCHMARK USED I
D
1W I APR __w
M
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed;
(krepaired;
by
VAA-C.,_
located at 71 D G' � -Po r4
C:ia
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit #_' dated , with an approved design
flow of . gallons per day. The materials used were in conformance with those
specified on the approved plan; the system was installed in accordance with the
provisions of 3 10 0vM 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:
Engineer Representative
Final inspection date:
installer:
Design Engineer:
Engineer Representative
Lic.#:0,15L Date:
Date:
4AY. 10 N2. I
t
'D ISPOSA 1. SYSTE:INT
'TOWN—OITNOR511 ANDOVER SEWAGE,
T ION
I-N-,STALLA CERTIFICATION
The und-ershmed here*_,y cer-tify that the Scwa2e Disposal Systern i const'�Jctcd-
('X)
bV_ Q
IW6 A./
located at. 2- -7
was installed in cbrifc-rmanct with the North AnC'ove,' Board of Heaith a-fprove� plan..
Svstem Design Pe.-;rl*t'.--' dated With an approved desi-n
flow of 'gailons per day The mate!7-'a;.s,use_,_, were in codormanct .%--1.-h those
specified oh the app*ro�71-d plan; th� sysienn was instafled in accorda�.0 '%'.11ith the provisions
of 31 10 CN.,fR 15.000, Title 5 a-nd local ret -i lations, and the final Qrad1P!.Z .12reos
su6stantially %%ith the approved plan. Ail workis accurateiv reoresented ��c �he As -built
%vhjch has been submitted to the Board cz- Health.
Bed inspection datI--.
Eneinecr
F I -on �are-
'na.1 inspect
Enspreer Represe�cai:%:e
Lnstal'er: Date. -
Cesium EnQilleer- Date, 57�10'zl
4P21
WHARD
C.
TANGARD co
CV
NAL
of
TOWN OF NORTH ANDOVER SEWAGE, DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed;
( )repaired;
by
located at
4
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit # dated with an approved design
flow of gallons per day. The materials used were in confori-nance with those
specified on the approved plan; the system was installed in accordance with the
provisions of 3 10 C�,M 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: _ 9W
Final inspection date:
Installei
Design
Engineer Representative
Engineer Representative
Lic.#: Date: q1z 5-/0 _z_
1-1
Date:
N & M Job nurfib�r 1770/-05-7.0
TOWN OF NORTH ANDOVER
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
rl -1 -7 fe"Pwfr- 0 5 -7— Final Date:
Site: —
Installer4 *Xo,�j ek,� A,H )611 1 A)
7 -01 z:7 z, �75
Date
A. Bottom of Bed 1A M/6 Z_ "V 6- . -
1. Excavation to proper depth 1
2. With trenches, sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation, etc.
Comments: (Use back of sheet for diagrams.)
//-7— /- c7 c,- le-- 7,, 1�7 001
B. Retaining Wall
I - Wall height and widathn -sp "if
2. Waterproofed
3. Wall min-i�6 10' t0eaffing facility
4. Walimeets specifications of plan
Comments:
C. Building Sewer
I - Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Inlet to tank cemented
4. Slope minimum 0. 0 1 or 1/8" per foot minimum
5. Pipe Properly set on compact firm base
6. Pipe laid on continuous grade in straight line
7- Cleanouts precede all change in alignment and grade
8. Manholes at any goo change
9. 10' minimum offset to water line
Comments:
D. Septic Tank
1. Level
2. 1,500 gal minimum
3. Gas baffle present on outlet
4. Manhole to w/in 6" of grade t/ M to -T'177
5. Manholes over center and each tee
6. 3-20" manholes
7. Outlet line cemented
8. 2" - 3" drop from inlet to outlet
9. Pipe set
10. Compact base with 6" of3/4" crushed stone under tank
11. Tank is watertight
12. Tees 12" off side of tank
Tel:
Yes No Initials
vd7- oev a—
r
N & M Job number 1770/ 15
Z Comments: Date
Yes
NO Initials
E. Pump Chamber
I. If separate from tank, compact base wi f stone underneath
2. Minimum 2" pipe to d -box if gravi tein
3. 20" access manhole
4. Tank level
5. Watertight
6. Tank size agrees�� plan specification
7. Manhole to grad
8. Check valz�d bleeder hole present
U. dii
9. Alarm uilding on separate circ
10. Alan imetions
11. Wual operating switch
12. Pump delivers liquid -box
Comments:
F. Distribution Box
1. D -box level
2. Minimum 0. IT' (2") drop from inlet to outlet
3. Minimum 6" sump
4. Outlet pipes show equal distribution
5. Compact base with 6" of stone beneaih box
6. Box is watertight
7. All lines cemented with hydraulic cement
8. Schedule 40 pipe
9. First 2' from box laid
level
Comments:
G. Soil Absorption system
1. All stone double -washed — 3/4 2
- pea stone
Bucket test done?
2. Minimum 2" of pea stone above distribution lines
3. Minimum 6" stone beneath
pipe
4. Distribution lines capped or connected together
5. Toe Of Slope Stops mi-iiinium 5' from edge of property;
5a. if not, then swale.
Comments:
N & M Job number 1770/ 0 5-7-6
H.- Leach Trenches
Date
1 - Minimum 2 trenches
2. Length of trenches agrees with pi ax. length 1001)
3. Width of trenches agrees VwAi an — Minimum 2'.
4. Vent present if >50 fee specified
5. Minimum distanc tween trenches 10'
�n M
u
6. Pipe slope,m' i um 0.005 or 6" per 100'
j 1
7. Depth ofEenches, below outlet mimurn of 6".
3
8. Pipes set on stable base.
Comments:
Yes No Initials
-------------
1. Leach Field
1. Maximum length of field 1,00,
Z— ripeslope MIMUMO-005or6"perlool
3- Separation between pipes 6' maximum
4. Pipes connected at end & Vent end raised 4----
5. Separation between adjacent fields 10' minimum
6- ' Pipes Set on stable base
7. Maximum 4' Separation from edge of field to first line
8- Minimum two distribution lines
Comments:
J. Leaching Pits
Min:iinum inlet pipe 4"
7
0 1
2. Pits of concrete
_w
3. Sidewall b een 12" and ;4f"
ol
4. Acc anholes on each
ulic ceu
5. Pipes cemented with -h" aulic cement
6.
Comments:
Final Grade
I . Slope over soil absorption system minimum 0.02
2. All system components covered by at least 9" soil
3. Cover soil free of stones larger than 6"
4. Grading slopes away from dwelling
5. No areas over system that may pond
6. Grading meets 3:1 slope
7. Minimum of 9" of fill graded over system
jo ON wo 0^04 Jv jr
cz)
Abr v
-;�?- r
1� Ar S V,
Ao,*40 *v a 4r Ic or **I all-$ -
SWALE VENT
98151b
73
98*7b �50'
—94
98*90
ON
6 LIMIT OF SAND
(see constructior
TP 2
P 1
\T P 1 PT 1
196
DISTRIBUTION BOX
APPROXIMATE LO.�
00,0 EXISTING LEACH,
PORCH 1500 GALLO.N SE
Lo
-IMATE
f99*75 2r7 APPROX LO
OF EXISTING SEF
EXISTING THREE
BEDROOM HOUSE
SILL ELEV 100.20
17 649A PPVOW
M W BENCHMARK: TOF
x
FRONT STEP. ELI
m �:j
1E z
PRESSURE WATER
SERVICE
Project Request Record
Town of North Andover
Date: �Iy _Z_
Client Id: ToNA
Card Id: ToNA Client/Company Name: �oard of Health
CArd?'.TT ve-Clkntt,
''Cbritactl Name: Ms.:-SandraStarr,
Phone:
978---68&954Q_.
Ti&:,Director
Fax.,
97&688`9542'.
s-. 27'Charles.Street.
Email. sstarr@townofnorthandover--.corii,,-
Notes:-
NortliAndover.
ff
State— Zip.Code:. 01"8451
OthO �.contacts;if,4 IR bI ine�r
p ca e: ie �Ehg,
e:!
Phone:
7&1 -2'
Fax:
'Ad ess:
Email:
Notes:
To wn.
"Stat6:.
Proiect:
Project Id: 1770 Project Title: Town of North Andover, Board of Health
(JOB NO) (PROJECT NAME & STREET ADDRESS)
Manager: NOW Billing Group: 7 '_Billing Cod(F-Fi=xedFee
T`,C6ntract,,Inf6., Project Description for each, billingi group
BG/i Applicant 7- lfj574
�`Ty
pe..of service,,
Office/fornis/jbrqutona
, f -,7 -1—
COMMONWEALTH OF MASSACHUSETTS
ExEcuTivE OFFICE OF ENVIRONMENTAL AFFAiRs
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: A -7 QRAQ�oc-C)
NGr,T1%. OKsoaye(L n
Owner'sName: 06rol�,j SrA okT6 r -j
Owner's Address: .1 R=Aor-a' TF
N (S C -Th AIJ06yem AA -
Date of Inspection:
Name of Inspector. 4tt-r LCricd-re-STA4
Company Name:
MailingAddress: lir j4AveAjjj sr
hmpaump- _j&Ar
Telephone Number. 977 - i-17f-1ciar
CERTIFICATION STATEMENT
J
TH
PUG
I cer* 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 fimpection, 7be inspection was performed based on my
training and experience in the proper fimction and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Tide 5 (310 (,'�M15.000� The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: -Z
Date: F 0)
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.
Notes and Comments
****nb report only describes cort4itions at the time of inspection and under the conditions of use at that
time. This inspection does not address haw the system. win perform in the future under the same or different
conditions of me.
%ge2ofIl
0 -
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: A2 BtAb"vc, r1-
&'T� Am d"f- MA
Owner. D6"Tk., s Ta.Ai Td Ij
Date of Inspection: ' 'g- 1 -01
Inspection Summary: Check AACD or E / complete all of Section D
A. System -Passes:
. I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 3 10 CMR 15.304 exist. Any failure afteria not evaluated am indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Paw" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (YNND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whediir metal or not) is structurally
unsotmd, exhibits substantial infiltration or exfiltration or tank failure is ftnr�mient. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the %ad of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or' unem distribution box. System will pan inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
4 distribution box is leveled or replaced
ND explain:
— The system requir-ed pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Pape3ofll
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ;L R Ir 0 Ti—
Owner.
Date of Inspectiba: 'T 0 1 — 8
C_ Further Evaluation is Required by the Board of Health:
Conditions exist which require fijrther evaluation by the Board of Health in order to determine if the system
is fiffling to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in.accordaDce with 310 CMR 15-303(l)(b) that the
system is not fimetioning In a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that -the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
�_w6e water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 5,0'ted of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system pases if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided &at no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
—.0-
Pape4ofll
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
, PART A
CERTIFICATION (continued)
Property Address: A 3 BRApZro
M,2 rTh A r4 pe v ea -
owner: SlAn kTo w
Date of &ipection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following fbr all inspections:
Yes No
Backup of sewage into fiLcility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surhce of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool -rg-e-r— Qoo—j S
v/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day flow
Required pumping more dw 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a sur&ce
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private witer supply well.
V 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 cerfified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free brom pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppmprovided that no other failure criteria
are triggered. A copy of the analysis must be attached to tbrs form.]
(Yes/No) The system &j!j. I have determined that one or more of the above failure criteria e)dst as
described in 3 10 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be consi . dered a large system the system must serve a facility with a design flow of 10,000 gpd to 1-9,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(Ibe following criteria apply tolarge systems in addition to the criteria above)
yes no
— — the system is within 400 feet of a str&ce drink ing water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or' answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a '
significant threat under Section E or fitiled under Section D shall upgrade the system in accordance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
-Pave 5 of I I
,a -
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddress: 34-7 0W.1jr-p &1'
M6rT'h
Owner. S'lulcTboj
Date of Inspechon: 1-1-01
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Pumping information was provided by the owner, oocupant� or Board of Health
Syor 114 MOT �Onp.o -Q.c- I/eAes
Werb any of the system components pumped out in the previous two weeks ?
V Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of the system obtained and exam p*ed? (If they were not available note as N/A)
plf,o DArco 14QI Po 'S N -T' -
0 'esci-11-c_ PT. 0011b F1W 4T -L4,LL
Was the facility or dwelling inspected for sips of sewage back up ?
_v"" — Was the site inspected for signs of break out ?
_Z Were all system components, excluding the SAS, located on site
Were the septic tank manholes uncovered opened, and the interior of the tank inspected for the
condition of the baffles or tees, gnpterial of construction, dimen ons, depth
Sam ? OuTLel' 13AWI-c- is Miss 105 si . Ig liquid, depth of sludge and depth of
V1 _ Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurikee sewage disposal systems ? ,
The size and location of the Soll Absorption System (SAS) on the site has been determined based on:
Yes no I
ormation. For example, a plan at the Board of Health.
,�A�Xisting inf
Determined in the field (if any of the fiLilure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
. orwa D Bo'v- -f, SrJALCO j cS
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1-7 BeApvof-p f�
_bC2PT'h
O*ner: ST4 101 CTO P-1
Date of Gpectioin: T -0 1 - 6 1
FLOWCONDMONS
RESEDENTIAL
Number of bedrooms (design): _3_ Number of bedrooms (actual): 3
DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x # of bedrooms): _3 3 0
Number of current residents:
Does residence have a garbage grinder Cyes or no): KZ
Is laundry on a separate sewage system (yes or no): LLO [if yes separate inspection required]
Laundry system inspected Cyes or no): WO
Seasonal use: (yes or no): _Y0 —
Water meter readings, if available Oast 2 years usage (gpd)): 06
Sump pump (yes or no): W
Last date of occupancy:
COMIERCLAIANDUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/Aftetc'.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL MORMATION
Pumping Records
Source of information: _Qwj4 er- SysTeh nuritcleA zr _IveAes
Was system pumped as part of the inspedion Cyes oi no): !No
If yes, volume pumped: ____gallons - How was quantity pumped determined?
Reason for pumping:
T
Y?E I�F SMEM
Y ePtic tank, distribution box, soil absorption system
— Single cesspool
— Overflow cesspool
— Privy
— Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
��ined from system owner)
— Tight tank — Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information:
lqcal
Were sewage odors detected when arriving at the site (yes or no): NO
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
-SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0j.-7 BkApVoc-o C -T -
Owner.
Date of &;pQon: -C) I
BUELDING SEWER (locate on site plan)
Depth below grade: 3 o
Materials of construction: _jj!fcast iron 40 PVC other (explain):
Distance fi-om private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
.IN
SEPTIC TANK- --locate on site plan) Ye -S
Depth below grade: It U I/ .
Material of constru� =n.--Zqoncrete fiberglass
. .. I ... __polyethylene
Tf ;nk is'=61 list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate) Qr
Dimensions: Ro 0 a 0
Sludge depth: i A�r-
Distance firom top of sludge to bottom of outlet tee or baffle: -rr C- MIS �'l vil
Scum thickness: 0
Distance from top Of scum to top of outlet tee or baffle: C1
Distance from bottom of scum to bottom of outlet tee or baffle: '3 V'171
How were dimensions dctetmined:_]��tc) :EWSj?eZ-Yjo0
Comments (on pumping recommendations, inlet and dutlet tee or baffle condition, structural integrity, liquid levels
as related to outlet inver
_� evidence of leakage� etc.):
1ILS - I ri r, — A, Do rT i o Pj a
5oj%0,& cAppy oule jDi Role
,C
GREASE TRAP: _(Iocate on site plan)
Depth below grade:
Material of construction: —concrete —metal —fiberglass __polyethylene —other
(explain):
Dimensions:
Scum thickness:
Distance from top Of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping6
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pave 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ;L'7 Okff4orc> ST-
K)Q ANOo%)ML M4 -
Owner. TTAn�cT6 eg
Date of i;s�on: _�_ a —o( —ol
TIGHT or HOLDING TANK " (tank must be pumped at time of inspectionXIocate on site plan)
Depth below grade:
Material of construction: —concrete —metal --fiberglass ---Polyethylene —other(explain):
Dimensions:
Capacity. ___ I Ilons
Design Flow. gallons/day
Alarm present (yes or no):
Alarm level: , Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
BQX-/
DIS"IRIBUTION �LS(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.):
O,jT- j p es
U 14; to -1 P'3 41 6'et r4 LU Ro amr
tAelt U tv—
ocate on site �Ianj
70
(3ox
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
0 1
PRQe9ofII
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: A-7 GRa D �or c3 v.T-
rTh. A i�joa v e (L,
Owner.. STqoly-Tor-j
Date of Inspection: J�-- �01 - o I
SOEL ABSORMON SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why -
Type
leaching pits, number:
leaching chambers, nu��:
leaching galleries, number:
leaching trenches, number, Fenjih: Trt r,3A es. Vpie,-cs L r- IT K
leaching fields, number, dimensions:
overflow cesspool, number: ,
innovativetalternative system Typelhame of technology:
Comments (note condition of soil, signs of hydraulic failure, level of Pondinz damt) soil. condition of veactation-
C\3%De*jCe. v' C -
"I S113091C CA?-9-y-a\)e -Prom I D 6oA To L ,,4 es
CESSPOOLS: — (cesspool mustbe pumped as part of inspectionXiocate on site plan)
Number and configuration:
Depth - top of liquid to mi'let invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of.cesspool:
Materials of construction:
Indication of groundwater infiow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIW: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hy draulic fiiiiure, . level of ponding, condition of vegetation, etc.):
X
Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2-7 &&QLer.
No 14% Af4poveo-
Owner. STA 0)-e- -ro tj
Date of Gpecti6n: o i - 0 1
SKETCH OF SEWAGE DISPOSAL SYMM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells. within 1.00 feet. Locate where public water supply enters the building.
OC
ROO mo
0y.
le
P,.0
A
'Sc rc c tq
Pc,,rc�\
A -r6 C (, G
-T- D
To. C
'To
. Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOS *
AL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: o9,-7 ST
Nor—) h Ata ;,og-cjL- MPr
Owner. fo"
Date of hopedion: _ A - oj-�- 0
SNE EXAM
Slope
Swface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
2' ONerved site (abutting PrOpertY/ObserVation hole within 150 feet of SAS)
Checked with local Board of Health-explain-
ve Checked with local excavators, installers- (attach documentation)
Accessed USGS databasp-cVlain:
essc?e cooST7 (3cololic-p-L SQ(-,jty
You most describe how you established the high ground water elevation:
S, -1.3 Ce1WL-
7S
BOARD OF HEAITH
T OWN CF NORTH ANDOVER
MASS.
7
P'p
1. NAME p.,oe �rl# I—
rO A,
0 & DATE GIV90 eve 0 ee 9 1090' 0
2. ADDRESS 60 6 0 a LOT NO. , 7 . . . . . . TEL.
3. NO, - OF BEDROOPB DEN YES No*
GARBAGE GRINDER, YES 0 0 N04 AO* o 9
SHOW DIMENSIONS OF HOUSE
6, SHOW DISTANCES OF HOUSE TO ALL PROFERTY LINES
7, SHOW DIMENSIONS OF L42
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKSO STREAMSO DITCHES2 LEDGE OTJTCROP9 ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL. REGULAT IOIZ SHOUID BE READ CAREFULLY.
IN ' k.
Permit NO:
Date Issued:
BUILDING PERMIT -
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received '
TYPE OF IMPROVEMENT
PROPOSED USE
-
Residential
Non- Residential
New Building
One family
Addition — 3 s6aso(o
So to
Two or more family
Industrial I
Alteration
No. of units:
Commercial
Others:
Repair, replacement
sessory Bldg
-9mmolition
Other
if
7 7g�7"
Aw la
'Y�.'Nm 77 p
n�
DE5CRIPTION
OF WORK TO BE PREFORMED:
/0 iff -I L0 1H L3
--A lo'exlq el 5uu))e5�k ro
77�(e
OWNER: Name
�z
Type or Print Clearly)
: Y7� -790 - -,Y
ARCH ITPT/ENG I NEER::� Uo(
A 0-0��s Phone:
Address:
Reg. No.
FEE SCHEDULEBULDING PERMIT: $JZOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: _FEE: $
Check No.: —Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Plans Submitted
Plans Waived
Certified Plot Plan
Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, ctc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTME NTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed o
S
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation: Decision: Comments
Water & Sewer Connection/Signature &.Date Driveway Permit.
DPW Town Engineer: Signature:
Located 384 Osgood Street
�'Vj Q�
'IT
'EN3
R1,RFM f T
R
�Iidi N ainiStreepw
- 44 N� Kr7;M �K
n'ZA
%
'v
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For department use
P161— Oclvk
Va, C� C -J,
El Notified for pic'kup - Date
Doc.Building Pemiit Revised 2008
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
L3 Building Permit Application
a Workers Comp Affidavit
Ei Photo Copy Of H.I.C. And/Or C.S.L. Licenses
a Copy of Contract
u Floor Plan Or Proposed Interior Work
Ei Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg,.,Permit
Addition Or Decks
L3 Building Permit Application
L3 Certified Surveyed Plot Plan
L3 Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
E3 Mass check Energy Compliance Report (if Applicable)
u Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
a Building Permit Application
u Certified Proposed Plot Plan
L3 Photo of H.I.C. And C.S.L. Licenses
L3 Workers Comp Affidavit
Li Two Sets of,Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Copy of Contract
• Mass check Energy Compliance Report
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The,applicant must then,get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENTMFORM07
Revised 2.2008
4 31
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D S T R E E T
BRADFOT .
150.00'
LIMIT OF' SA
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TIP 2
1500 GALLC
BENCHMARK
FRON7 STEF
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BOARD OF HEAITH
TOWN OF NORTH ANDOVERt MASS.
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DATE
1. NAME P./l. Y*r",�o
r—o il 7 . . . . . . TEL.
2. ADDRESS 0 & 0 * . . . LOT NO. .
3. NO. OF BEDROOM . ��. . . DEN YES . NO*
4. GARBAGE GRINDM YES 0 & 6 0 6 NO. Ac. . .
5. SHOW DIIJENSIONS5 OF HOUSE 1 1
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7, SHOW DIYlENSIOl\rb 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 BROOKS9 STREAMS, DITCHES, LEDGE OUTCROPs ETC -
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
tEFULLY,
NOTE: LOCAL REGULATIONS SHOULD BE READ CAP