HomeMy WebLinkAboutMiscellaneous - 286 RALEIGH TAVERN LANE 4/30/2018 (2)ND
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of.- 10/20/2014
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair of Tank and D -Box
of this
ichele Grant
Public Health,
By: Todd Bateson
At:
286 Raleis!h Tavern Lane
Map 106.0 Lot 0111
orth , ndover, MA 01845
)shall not, e construed as a guarantee that the system will function satisfactorily.
1600 Osgood Street, North Andover, Mass achusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.(om
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
4:1
Commonwealth of Massachusetts
Title 5 Official Inspection Fo
Subsurface Sewage Disposal System Form - Not for Voluntary /
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner's Name
North Andover
Cityfrown
MA 01845
State Zip Code
Smeqjit0,'-.j fj
-rov%IN 17�
rll:�' -
10/21/2014
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterp
Company Name
111 Argilla Road
Company Address
Andover
Cilyfrown
978-475-4786
Telephone Number
B. Certification
Inc.
MA
State
S115
License Number
01810
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
0 Passes El Conditionally Passes [I Fails
Nee" Further Eval ti n by the Local Approving Authority
10/21/2014
InspWor0ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time Of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavem Lane
Property Address
Ira Sarver
Owner
information is
required for
every page.
Owners Name
North Andover MA 01845 10/21/2014
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from B.O.H., install new septic tank & d -box, inspection from B.O.H., septic system now
passes Title Inspection.
B) System Conditionally Passes:
El One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain. -
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or 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.
EJ Y F1 N [I ND (Explain below):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form 7 Z Z014
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I TOWN Uli- NUK I h ANDOVER
L_�EALTH DEPARTMENT
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner's Name
North Andover MA 01845 10/21/2014
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
M hand -sketch in the area.below
El drawing aftached separately
,4
0
A'0
0-P_>"Y-_Lf
C-)
D-49�c)y
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
LOCATION:
H/0 NAME:
CONTRACTOR NAME:
Me E
I
ri
Type
of Permit or License: (Check box)
Town of North Andover
•
Animal
$
HEALTH DEPARTMENT
3A
C ECK #:
q
_DATE:
LOCATION:
H/0 NAME:
CONTRACTOR NAME:
Me E
I
ri
Type
of Permit or License: (Check box)
• Swimming Pool
•
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
•
Food Service - Type:
$
•
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0 Sun tanning
$
• Swimming Pool
$
• Tobacco
$
• Trash/Solid Waste Hauler
• Well Construction
SEPTIC Sustems:
• Septic - Soil Testing $
• Septic - Design Approval $
0 Septic Disposal Works Construction (DWQ $-
0 Septic Disposal Works Installers (DWI) $
0 Title 5 Inspector $
KTitle 5 Report $:5r, �
0 Other (Indicate)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
SEP77C Sustems:
0 Septic - Soil Testing $
0 Septic - Design Approval $
0 Septic Disposal Works Construction (DW0 $
0 Septic Disposal Works Installers (DWI) $
0 Title 5 Inspector $
�� Title 5 Report $:!asl
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
66bO
4F Town of North Andover
HEALTH DEPARTMENT
C U
CHECK#: q DATE:
LOCATION.
1-1/0 NAME: y
CONTRACTOR NAME:
Type of Permit or License: (Check box)
0 Animal
$
0 Body Art Establishment
$
0 Body Art Practitioner
$
0 Dumpster
$
• Food Service - Type.-
$
• Funeral Directors
$
0 Massage Establishment
$
0 Massage Practice
$
0 Offal (Septic) Hauler
$
0 Recreational Camp
$-
0 Sun tanning
$
0 Swimming Pool
$
0 Tobacco
$
0 TrashlSolid Waste Hauler
$
0 Well Construction
$
SEP77C Sustems:
0 Septic - Soil Testing $
0 Septic - Design Approval $
0 Septic Disposal Works Construction (DW0 $
0 Septic Disposal Works Installers (DWI) $
0 Title 5 Inspector $
�� Title 5 Report $:!asl
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
D L
WI,'
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
0*--�
vs�=A
,Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessmentv--
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner's Name
North Andover
Cityrrown
MA 01845
State Zip Code
12/12/2013
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
Cityrrown State
978-475-4786 S115
Telephone Number
B. Certification
License Number
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system: F—RE C-EIVED7
EJ Passes
Z Conditionally Passes Ej F
Ej Needis FurthLor Evaluation by the Local Approving Authority
12/12/2013
InskeVo(' s Signat4A Date
c -c 3 0 ?013
TOWN QFNUR1 H ANDOVER
HEALTH DEPARTMENT
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
.f,\ ,Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner Owners Name
information i's
required for North Andover MA 01845 12/12/2013
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
13) System Conditionally Passes:
Z One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
E Y [:1 N El ND (Explain below):
Tank level 4" below outlet invert. tank leakin
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System, Page 2 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owners Name
North Andover MA 01845 12/12/2013
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
El broken pipe(s) are replaced
R obstruction is removed
0 Y [E N Ej ND (Explain below):
F1 Y Z N El ND (Explain below):
F� distribution box is leveled or replaced El Y Z N F-1 ND (Explain below):
F1 The system required pumping more than 4 bmes a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
F1 broken pipe(s) are replaced El Y Z N El ND (Explain below):
[:1 obstruction is removed El Y Z N [I ND (Explain below):
C) Further Evaluation is Required by the.Bolard of Health:
F� Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,! safety or the environment.
1. System will pass unless Board of Hea i Ith determines in accordance with 310 CMR
16.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
MIMI
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owners Name
North Andover
City/Town
B. Certification (cont.)
MA 01845
State Zip Code
12/12/2013
Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El The system has a septic tank and,soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
F-1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
R The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
Tank & D -box needs to be
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
El
0
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
Z
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
1:1
z
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
Z
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
-�' N Commonwealth of Massachusetts
oTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Raleigh Tavern Lane
,r
Property Address
Ira Sarver
Owner Owner's Name
information is North Andover MA 01845 12/12/2013
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
1:1 z
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
11 z
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El z
Any portion of a cesspool or privy is within a Zone 1 of a public well.
0 z
Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
El Z
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
El z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
n El the system is within 400 feet of a surface drinking water supply
E] 1:1 the system is within 200 feet of a tributary to a surface drinking water supply
El El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner Owners Name
information is
required for North Andover MA 01845 12/12/2013
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
IR El Pumping information was provided by the owner, occupant, or Board of Health
El Z Were any of the system components pumped out in the previous two weeks?
Z F� Has the system received normal flows in the previous two week period?
EJ Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z 11 Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z F-1 Was the facility or dwelling inspected for signs of sewage back up?
Z 1:1 Was the site inspected for signs of break out?
Z 1:1 Were all system components, excluding the SAS, located on site?
Z El
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Z 0
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Z 1:1
Existing information. For example, a plan at the Board of Health.
Z El
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions*
A
Number of bedrooms (design):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
A
r_- =Iks
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner
Owners Name
information i's
required for
North Andover MA 01845 12/12/2013
every page.
Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
3
Does residence have a garbage grinder?
El
Yes
Z
No
Is laundry on a separate sewage system? (Include laundry system inspection
El
Yes
Z
No
information in this report.)
Laundry system inspected?
Ej
Yes
[]
No
Seasonaluse?
El
Yes
Z
No
Water meter readings, if available (last 2 years usage (gpd)):
Yes
Detail:
Sump pump'?
El
Yes
0
No
Last date of occupancy:
Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
El
Yes
El
No
Industrial waste holding tank present?
El
Yes
F�
No
Non -sanitary waste discharged to the Title 5 system?
El
Yes
El
No
Water meter readings, if available:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner Owners Name
information i's
required for North Andover MA 01845 12112/2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
Pumped September 2012, owner
gallons
El Yes Z No
Type of System:
E Septic tank, distribution box, soil absorption system
El Single cesspool
Overflow cesspool
Privy
E-1 Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
El Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 117
<n�x . Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner Owner's Name
information i's
— i—A f— North Andover
every page. Cityrrown
D. System Information (cont.)
MA 01845 12/12/2013
State Zip Code Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
31 years old, 10/2/1982, as built plan.
Were sewage odors detected when arriving at the site? El Yes 0 No
Building Sewer (locate on site plan):
Depth below grade: 1.3
feet
Material of construction:
Z cast iron Z 40 PVC El other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" cast iron throuqh floor, 3" PVC in house, no leaks visible
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete M metal
.3
feet
El fiberglass El polyethylene El other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10'x 5'x 4'
Sludge depth:
2"
0 Yes 0 No
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Owner
information is
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
Septic Tank (cont.)
MA 01845 12/12/2013
State Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
N/A = tank leaking
2"
N/A
N/A
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee badly corroded. Outlet cover broken. Depth of liquid below outlet
invert 4". Evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
D concrete 0 metal
Dimensions:
Scum thickness
feet
F� fiberglass El polyethylene [I other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
IN Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owner
information is
required for
every page.
Owner's Name
North Andover MA 01845 12/12/2013
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
D concrete El metal El fiberglass El polyethylene [I other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
El Yes El No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
El Yes [I No
* Attach copy of current pumping contract (required). Is copy attached? El Yes F-1 No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
-�C\ - Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
,p
perty Address
Ira Sarver
Owner
information i's
required for
every page.
Owner's Name
North Andover MA 01845 12/12/2013
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box cover broken,replaced same. D -box badly corroded,needs to be replaced.
Evidence of carryover. Evidence of leakage,has holes in box.
Pump Chamber (locate on site plan):
Pumps in working order: El Yes No*
Alarms in working order: El Yes F� No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Owner
information is
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owners Name
North Andover
Cityrrown
D. System Information (cont.)
Type:
El
leaching pits
El
leaching chambers
El
leaching galleries
z
leaching trenches
E-1
leaching fields
R
overflow cesspool
MA 01845 12/12/2013
State Zip Code Date of Inspection
number:
number:
number:
number, length: 3 trenches 72'
long
number, dimensions:
number:
0 innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes F-1 N o
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owners Name
North Andover MA 01845 12/12/2013
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
T a
itle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owners Name
North Andover MA 01845 12/12/2013
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
Z hand -sketch in the area below
El drawing attached separately
wc-A�
'4
C,
A4v I ;MkIolt
043o?- -3k4
t5in.s - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
Property Address
Ira Sarver
Owners Name
North Andover
Cityrrown
D. System Information (cont.)
Site Exam:
9:c+imn+,mr4 An +K +n Ki In rr%"nr4 tAin+,mr*
MA 01845
State Zip Code
>41
12/12/2013
Date of Inspection
F ZJ �J feet
Please indicate all methods used to determine the high ground water elevation:
a
I
I
Obtained from system design plans on record
If r-hint-knnrf rinfin nf riaci n Inn ravidauudatim
5/24/1980
I U r, Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Desian Dian
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Check Slope
Surface water
Z
Check cellar
Z
Shallow wells
9:c+imn+,mr4 An +K +n Ki In rr%"nr4 tAin+,mr*
MA 01845
State Zip Code
>41
12/12/2013
Date of Inspection
F ZJ �J feet
Please indicate all methods used to determine the high ground water elevation:
a
I
I
Obtained from system design plans on record
If r-hint-knnrf rinfin nf riaci n Inn ravidauudatim
5/24/1980
I U r, Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Desian Dian
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
g,\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Raleigh Tavern Lane
01845 12/12/2013
Zip Code Date of Inspection
Z Inspection Summary: A, B, C, D, or E checked
Z inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in! separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Property Address
Ira Sarver
Owner
Owner's Name
information i's
required for
North Andover MA
every page.
Cityrrown State
E. Report Completeness Checklist
01845 12/12/2013
Zip Code Date of Inspection
Z Inspection Summary: A, B, C, D, or E checked
Z inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in! separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
286 RALEIGH TAVERN LANE
N 0 RTH AN DOVE R, MA 0 1845
UB Account Maint.
Account No Cycle Occupant Name Active/inactive
Bldg Id. 14104.0 - 286 RALEIGH TAVERN LANE Last Billing Date 9/9/2013
2100084 02 Cycle 02 Active
UB Services Maint.
Account No. 2100084
Service Code Rate Charge - Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 136.67 /1
UB Meter Maintenance
Account No. 2100084
Summary Record Card generated on 12/4/2013 2:43:30 PM by Karen Hanlon
Page 1
Town North Andover Test
Serial No Status
Location
of
Type Size
YTD Cons
32772575 a Active
Tax Map # 210-106.C-01 11 -0000.0
ERT HH
b Badger
w Water 0.630.63
Parcel Id 17744
Date
Reading
Code
286 RALEIGH TAVERN LANE
Posted Date
Variance
8/1/2013
IRA SARVER
a Actual
31
9/18/2013
286 RALEIGH TAVERN LANE
5/1/2013
1122
a Actual
NORTH ANDOVER, MA 01845
6/18/2013
Class
101 Single Family
Property Type
1 Residential
Zoning2
1 Residential
Zoning3
1 Residential
Size Total
1. 14 Acres
25
12/13/2012
FY
2014
1056
a Actual
UB Mailing
Index
154%
5/2/2012
Name/Address
a Actual
Type Loan Number Active/Inact. From
Until
IRA SARVER
2/2/2012
Owner
a Actual
286 RALEIGH TAVERN LANE
N 0 RTH AN DOVE R, MA 0 1845
UB Account Maint.
Account No Cycle Occupant Name Active/inactive
Bldg Id. 14104.0 - 286 RALEIGH TAVERN LANE Last Billing Date 9/9/2013
2100084 02 Cycle 02 Active
UB Services Maint.
Account No. 2100084
Service Code Rate Charge - Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 136.67 /1
UB Meter Maintenance
Account No. 2100084
Serial No Status
Location
Brand
Type Size
YTD Cons
32772575 a Active
ERT HH
b Badger
w Water 0.630.63
777
Date
Reading
Code
Consumption
Posted Date
Variance
8/1/2013
1153
a Actual
31
9/18/2013
55%
5/1/2013
1122
a Actual
18
6/18/2013
-15%
2/7/2013
1104
a Actual
23
3/13/2013
-18%
10/30/2012
1081
a Actual
25
12/13/2012
-34%
8/2/2012
1056
a Actual
39
9/26/2012
154%
5/2/2012
1017
a Actual
15
6/20/2012
-22%
2/2/2012
1002
a Actual
20
3/14/2012
-14%
11/1/2011
982
a Actual
23
12/15/2011
-55%
8/1/2011
959
a Actual
50
9/14/2011
139%
5/212011
909
a Actual
20
6/13/2011
-13%
2/4/2011
889
a Actual
25
3/15/2011
-52%
11/1/2010
864
a Actual
50
12/13/2010
-36%
8/2/2010
814
a Actual
78
9/13/2010
239%
5/3/2010
736
a Actual
23
6/9/2010
-4%
2/1/2010
713
a Actual
24
3/11/2010
-69%
11/2/2009
689
a Actual
77
12/11/2009
64%
8/3/2009
612
a Actual
46
9/11/2009
107%
5/6/2009
566
a Actual
23
6/16/2009
-18%
2/3/2009
543
a Actual
28
3/16/2009
-60%
11/3/2008
515
a Actual
72
12/10/2008
5%
8/112008
443
a Actual
67
9/12/2008
202%
5/1/2008
376
a Actual
21
6/1812008
-12%
2/4/2008
355
a Actual
26
3/14/2008
-66%
11/1/2007
329
a Actual
73
1/15/2008
-7%
8/3/2007
256
a Actual
80
9/14/2007
263%
5/3/2007
176
a Actual
17
6/26/2007
-5%
2/21/2007
159
a Actual
28
3/23/2007
-3%
11/2/2006
131
a Actual
19
12/22/2006
-51%
8/21/2006
112
a Actual
58
9/13/2006
42%
5/4/2006
54
a Actual
34
6/20/2006
18%
2/2/2006
20
a Actual
20
3/13/2006
-100%
L
Commonwealth of Massachusetts " �D
7" 2 7 2014
City/Town of
TOWN 08c: NORTH ANDOVER
S i tem Pumping Record '0' P 0
M T
HEALT
YS L H DEPARTMENT
Form 4
DEP has provided this form for use -by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using -this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facili.t3f. Information
1. System Location: Left / Right front of house(j;W] Righ'A�5�f ho�use Left. / fight side of house, Left
Right side of building, Left / Right front of building, Left/'R_19Wr—eaFr-6T building, Under deck
Address
Cilyfrown
State
Zip Code
2. System Owner
Name'
Address (i different from location)
c4frown
stale Zip Code
Telephone Number
B. Pumping Record
i. Date of Pumping Y C_ % * guantity Pumped: 16
Date Gallons
3. Type -of system*- Cesspool(s) (1-S-eptic Tank El Tight Tank
[I Other (describe):
4. Effluent Tee Filter present? n Yes �o �� If yes, was ft cleaned? 0 Yes 0 No,
5. Condition of �y
6. System Pumped By -
Nell Bateson
Name
Bateson Enterprises Inc-
-dompany
7. Loca
forrwbere contents- were disposed:
Waste Water
F5821
Vehicle Ulcense Number
Date
-C
t5fbrm4.doc- 06/03 System Pumping Record - page I of 1
%._'A
North Andover Health Department
(ommunity Development Division
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 286 Raleigh Tavern Lane. MAP:
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
D -Box and TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
LOT:
9 Contractor reports any changes to design plan
Existing septic tank properly abandoned
Internal plumbing all to one building sewer
El Topography not appreciably altered
SEPTIC TANK
D/ Building sewer in continuous grade, on
compacted firm base
Cleanouts per plan
Bottom of tank hole has 6" stone base
Weep hole plugged
1500 gallon tank has been installed
H-10 loading
Monolithic tank construction
F-1 Water tightness of tank has been achieved by
visual testing
El Inlet tee installed, centered under access port
.0
Comments:
PUMP CHAMBER
Comments:
CONTROLIPANIEL
Comments:
DISTRIBUTION -BOX
Comments:
Outlet tee installed, centered under access port
(gas baffle/effluent filter)
inch cover to within 6" of finish grade
/ installed over one access port
EZ Hydraulic cement around inlet & outlet
F� Bottom of tank hole has 6" stone base
Ej Weep hole plugged
F-1 1500 gallon Pump Chamber installed
F-1 H-10 loading
Monolithic tank construction
Inlet tee installed, centered under access port
Ej Pump(s) installed on stable base
F-1 Alarm float working
F-1 Pump On/Off floats working
F-1 Separate on/off floats
F Drain hole in pressure line
El cover at final grade installed over pump
access port
F-1 Water tightness of tank has been achieved by
testing
F-1 Hydraulic cement around inlet & outlet
R Alarm & Pump are on separate circuits
El Alarm sounds when float is tripped
Location of control panel: basement
Alarm signal located inside: basement
I UV
N
S
Installed on stable stone base
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
peed levelers provided (not required)
Schedule 40 PVC Pipe
41 1
QlnwA-0110 r
Commonwealth of Massachusetts Map -Block -Lot
106.CO1 11
-----------
BOARD OF HEALTH Pennit No ------------
North Andover - BHP -2014- - 07 - 64 ----
------------ -- --
P.I. FEE
F.I. $125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd -Bate -son -----------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System. -�V
atNo - 2-8-6- RALEIGH -TAVE-RN-LANE ----------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. -BB-P-20 - I - 4 - - - 076 -- d.---Septe b ----- 3,2014
e,
------------------------------------------------------ 7 ---- ----
I ssued On: Sep -03-2 0 14 BOARD OF HEALTH
- ------- ---- ---- ------ - ---
k.,
Commonwealth of Massachusetts
Map -Block -Lot
106.CO1 11
BOARD OF HEALTH
-----------------------
Permit No
North Andover
BHP -2014-0764
-----------------------
FEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted -Todd -B-ateson -----------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System. 66
atNo - 2-8-6- RALEIGH TAVERNLANE ....... I
aflL4-_-_1 -------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. -BB-P-2-01-4---076 --- Dated . --- September _03,_ 2014
Issued On: Sep -03-2014
COM---- 0- _F --- H --- E A L T H_ ------
0
0
Town of North Andover
CHU
CHECK#:
LOCATION
H/O NAMI
CONTRACI
6991
Type
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$-
0
Well Construction
$
SEPTIC Sustems:
0 Septic - Soil Testing $
0 Septic - Design Approval $
Septic Disposal Works Construction (DWQ
Septic Disposal Works Installers (DWI)
0 Title 5 Inspector $
11 Title 5 Report $
0 Other (Indicate) $-
06
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
3. Installer Information
Name
bt A!tj,-- 114 f4
Address
A�
Cityrrown
4. Designer Information
Name
Address
City/Town
— FBATMONENTERPRISMS- INC
Name of lompan-PI ARGILLA ROAD-
ANDOVER.MA01810
State Zip Code
Telephone Number (Cell Phone # ffpossible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
Application for Septic Disposal Svstem
Construction Permit - TOWN OF
TODAYS DATE
NORTH ANDOVER2 MA 01845
$ 2501.00 – Full Repair
$1,25.00. - Component
Important:
Application is hereby made for a permit to:
When filling out
Construct a new on-site sewage disposal system*
forms on the
computer, use
Repair or replace an existing on-site sewage disposal system*
only the tab key
"a ir or replace an existing system component - What? 1,4,�jk
-,R- b- 'Q),,x
to move your
cursor - do not
use the return
A. Facility Information
key.
A V,
Address or Lot #
RECE; ED
City[rown
SEP U 2 2014
2.- *TYPE OF SEPjJ"YSTEM*:
> E] Pump [BSravity (choose one)
TOWN OF NORTiH ANDOVER
�lf pUmjLsygpi,-sttach copy of electrical permit to application
HEALTH DEPARTMENT
> HTonventional System (pipe and stone system)
> E] Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
> [] Pressure Distribution SAS. (No D -Box)
> F1 Pressure Dosed (D -Box Present) SAS.
> 0 Does the system require an effluent filter? Yes No
ff yes, does plan specffy make and model of fliter? YES = (no further info. needed)
NO = (installer must specffy brand of filter before DWC issuance)
WAst is the Makc?_ Wha t is the Model:-"
2. Owner Information
Name ce
Address (if different from above)
W,11 A&
Cityrrown State Zip Code
F2�—
-
Telephone Number
3. Installer Information
Name
bt A!tj,-- 114 f4
Address
A�
Cityrrown
4. Designer Information
Name
Address
City/Town
— FBATMONENTERPRISMS- INC
Name of lompan-PI ARGILLA ROAD-
ANDOVER.MA01810
State Zip Code
Telephone Number (Cell Phone # ffpossible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
ONTO# Application for
411,611, Septic Disposal Svstem
4/ -
S DATE
Construction -Permit' TOW N. OF -
-ORTH ANDOVER, MA 01845 $.250.00 � Full Repajr
C $125.00.- Component
PAGE 2 OF 2
A. Fadility. Information continued....
5. Type,of BuIldin-g: �esidential Dwelling or [DCommercial
B. Agreement
The unders* Igned agrees to ensur * e the construction and maintenance of the afore -described
On-sIte sewage disposal system In accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurhice Disposal Regulations for the Town of
North Andover, and not to place the system 1h operation until a Certificate Of Compliance has
been Jssuadpy this Board of Health.
Nam Wte
Application Approved By: (Board of Health Representative)
Name
Date
Application Disappr.oved.. for the following reasons:
For Offfee Use Only:
Yes No
2- P--0ie`ctAf9da?Ct ObEgadon Form Attach -ed? yis
3- F= -Mqo� Attach cQpy YCS
4. Foundation As-Buat? (new cOnstrUCtIon -ronly).-
Yes
(Same scale fisapprovedplaq).
.5 FloorPhns? (new Construction only)..
i�pp!Tc;�tic5nfor,Di�potal*st�M�odn�tructio Permft,Page202
n
C.MTIM.
As fl*Nqsth Andovgr &Mwed jumlla I ftlhe septic qstem.&r.
tht-PrOptdy At
)AV, 4AI
of sepdc IPU=) pUm by
ROadve to thg,,PPHmdft of leA&L
tmuces AM dated
Dated
WA 1�d�w dated'
t fevised. dstel
I uAdMand the folloWing jb�bjjgatio= fot milnag=cat oftWs p
1. As the insuR94 I a,mobl4ated -to 6bWa an p=jift and Bpard ofHealth
at,bmi4g any. . woA da a aity-- to
it- site
Utz d=
2. As f6fntWjeA,j
A*sV#U for my =d A tt.0 lehokneo'"e*j- contmctQl;pzojeCt m2ngga, Ox SMY
OOIUPcmon lot *540eWed wlth rqd=pky 9644
.0 Im Inspibeim wd the qatein i3 not rejcj� thlift
item 6me "bli
3- T'atl��iqlZ_Ejxd to, hwmthi get*
4M�W-C&IMO# - 'PdOft th
ladWited b4m, Ig Nt
`jfA'fijg
th
g
jrpw ftTectioll but does eet 14ve W b4 pravbri�-
EW lft� e
14�&4xei iiilbiam L
gag
t�biwt6md.to-ihc Bmrd-of Z-rw* 164i,;i f= -an h6m the Coginedr;nwt
Pecf4m titur_:I�stOer tnust
he.ptf��t &r th fnspccd* VA 6�
must- rewy and able to'
C. lbotolir =Ust mqWtlWdcdm Wheo -$&.gmdJnjji Calr&te,. ln"iidoes lo,ot
hkve to ke owfitp-
4. A -s -the ipWje4-j utj� that 047 I=
COt .
4plete th&jns.t�&ton Of e spte� f a th� jktN4
5.
6.
LNOrm Alla0vAr, MMbmt finsl to SH ch kbIndAe ili6 ggfigg�
perf=�Ce Df thi foRowifts CC=kactkm.
Steve..
Pc&�Oft afthelogodmdodde-o6i used
d Imts& do 6f&j* D_,Qox�
8=4 vwff OAmbrw, zeW
PY?* - Pl�p liv wag;Rd O&Cr
COMPWW&.
To
daes
r v
VA -1/ 0/�� _2�Vel?7
OCILT
7"119 Al k
At /,�' 0
-./ J A /
AV I'n
o
0
A,�A- ly. . 0
4c, u r
Boa.rd qf Haalth
North An&)ver,X"9.
W
1.
V1 I
A
BEPTIC SISTEM
INMILATICK CHECK LIST
CW
1. Distance Tot
a. Wetlands
b. Drains
0. Well
2. Water Line Location
LOT ?,&Uerq -111q.
4. Septic Tank
a. -Tess �_,Length & To Clean Out Covers..
b. Cement Pipe to Tank - on Both Sides of Tank
5. Distribution Box
a. Covers.& Box - No Cracks
b. All Lines Flowing Equal Amounts
C. No Back Flow
Leach Field or Trench
a. Dimensions
b. Stone Depth -ij$ce
-.c7 tot
a*- Capped -Eads
d. Clem Double- Washed Stone'
7. Leach Pits
a. Dimensions
b. Stone D
C. Spla ads
11 T
t Pipe to Pit Both Sides.
8
f Clean Double Washed Stone
'at- C e7p!
8. No Garbage Disposal
9. Yinal Grading Inspection
10. Barricading Covered System
11. As Built Submitted. C4, jeo-rif-I C-A-TIC9 *-j
a* Lot Location
b. Dim-ensions of System
c. Location with Regard -to Pere Test
d. Elevations
a. Water Table
ATICK OK FAIL
TO:
F ROM:
NORTH ANDOVER, MASS .19
BOARD OF HEALTH
DESIGN ENGINEER
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
7- /1 L/C CA 7 -Al Ve R 1v Z- oq Al North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in ney plans and specifications dated
ARC A 2%5- by G'C I, llvq 5 ssoclq rE-5
ClY C / AIFcl� / Al -:5Z-
/V o -t t= A 5 / /V G Rc) (A N 0 PLA /V
1p,' eer/ ff-witarian
Co
TO:
F ROM:
NORTH ANDOVER, MASS
BOARD OF HEALTH
DESIGN ENGINEER
Or- -T X
19 e?2-
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
JIV Z /I A16
r14 V,67,( North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
M A /z cA i 9-.rf—I . N,6 V/516 D
A16'rr /is Sua-r P-1AA1
r-oard of Yc�,Ith
17 rth findbvor ,Mass
SUBSURFACE DISPOSU DMGN CHECK LIST
LOT
APPRUIED DATE
DISAPPROM DATE
Provided:
Reasons:
Title V
OK
Reg 2.5
The
submitted plan mast show as a mziniraum:
the lot to be served-are-.a.,dimersic.n,,7 lot #,,ab-atters
ties
location and log deep observation hoies-distance to
location and remilts pamolation tests- di stzaice to ties
design calculations & calculations chowing m--qaireA leaching area
location and dimenvions of syste-m-including reserve area
L",
existing and proposed contours
location my vat areas i4thAn 1001 of SGVMCS disposal Sy3teM or
disclaiir3r-check watlands mapping
(h)
surface and aubsurfaco drains within 1001 of seyr-age disposal
"0'
systam or disclaimer
(i)
locaticn any &-alnege ease-sr.ents with -in 1001 of sas;age cUE-posal
-
system. or disclaiv"er-MA-ning Board files
/,0
(J)
knom sourees of rn-ter supply uit-h5n 2001 of sewage dispocal
system or dIscl----b,,,er
location of my. proposed. vv.11 to serve lot -1001 from leaebing facility
1)
location of rater lines on propcsrty,-100 A;= leaching facilit7
1)
loc�ation of benohmark
n)
&ive-.mys
garbage diaposals
n,
no PVC to be used in construction
)
proffle of s7atsm-elavation3 of basez-,,eant.. pluz-bt pipej, sc-piic tank.,
6istribution box Wets and outlets., distribution field piplmg W -Id
Otter elevatians
L./
)
n.aA7,aam groimd water eloWation in area se�rage diVpaial syst4m
(s)
plan wast be prapared by a Professional Fbg4meer or other
prof os,,E�ion-al authorize"d by law to prc-pare suc-h plans
F c,
Svtic. Tanks
(a)
ZWT—C%CINM-�L,1�0% of fl -ow., vater tany)le., tcest drpth of tees.,
accecs., pils.--ping
I/
(,b)
clwmout
:31ke)
101 from cellar -,,,--aU or ingromd m4rundmg pool
(d)
251 from Tabawface &J--ne
Reg 10. 2 Distribution Boxes
I /ka) slope greater t -F= O.OtI
Reg 10.4 mzp
si Check TA
,uxfac:e Dz- gn
FAIL I OK
Reg 9.1
9.6
P a P,' e 2
Lewhine Pits
Leaching pits Zare preferred where the installation is possible
'a) calculat ns of leaching area-ninimm 500 sq ft
b) spacin
c
d� e drainage 2%
ov fF
material
e) 21 140 splash pad
f) tre at elbow
g) no bends in pipe from d -box to pipe
a) Fo--gr-O-at-q�t �aan 20 minutes/inch
b) rd M 900 aq ft
- re'
C) =co as tion of field
A) mw e 2 %
e) 201 m cellar v, -a.0 or inground cnAm,-Ang pool
Lea-ching Trenches
I ---
a), cif MIN—lis OTTeaching area-rdn 500 sq ft,
.V) spacing -4 ft idn 6 ft with reserve bet,,-,ga
e) divamidons
4) 13t*ne "% �
f) Tarface drainage 2%
Dall"mUll 1'3 e
4
a) Rope &x to be shov.-n)
s
(t4
b) 7/X x (to be mho-,va)
a) aup
b) sl nd-by power
Reg 1-1. 2
11.4
11.10
Reg 15.1
15.4
15.8
3.7
Reg 3-4,1
14.3
14.4
.6
14-7
ILIO
Reg 9.1
9.6
P a P,' e 2
Lewhine Pits
Leaching pits Zare preferred where the installation is possible
'a) calculat ns of leaching area-ninimm 500 sq ft
b) spacin
c
d� e drainage 2%
ov fF
material
e) 21 140 splash pad
f) tre at elbow
g) no bends in pipe from d -box to pipe
a) Fo--gr-O-at-q�t �aan 20 minutes/inch
b) rd M 900 aq ft
- re'
C) =co as tion of field
A) mw e 2 %
e) 201 m cellar v, -a.0 or inground cnAm,-Ang pool
Lea-ching Trenches
I ---
a), cif MIN—lis OTTeaching area-rdn 500 sq ft,
.V) spacing -4 ft idn 6 ft with reserve bet,,-,ga
e) divamidons
4) 13t*ne "% �
f) Tarface drainage 2%
Dall"mUll 1'3 e
4
a) Rope &x to be shov.-n)
s
(t4
b) 7/X x (to be mho-,va)
a) aup
b) sl nd-by power
TOWN OF -Al
41 &3L
SYSTEM PUMPING RECORD
DATE: L-0- 1�
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
�)� I �� � 0-cv �— w v---) --(-,
DATE OF PUMPING: -1,� -6ol-- QUANTITY PUMPED: SOL GALLONS
CESSPOOL: NO YES "Ei"PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE :7 EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: ( L S' b
_�V
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
Ahereby e app ication for a permit for a sewage disposal installation at
.'l- / 6 - _t4ut daL 41 1 will install this system in ac-
cordance with all the Aaws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1916 until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of le—V4 in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of ?_ '1 0 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 i7ch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/81, to 1/41, (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
Ifurther agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be� �Ubitted with application.
cle
DATE 0 ;:�'
ture of Api-511cant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts
DATE___ 171
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as des ib d*
DATE
Percolation Test 117Z'U�
Garbage Grinder
Signature of I (le cti—ng Officer
�j
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
V1
w
so
1,
S�6 ?�
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
1.
NAME—
DATE
2.
ADDRESS A"
J&
-
tdwL�I-ILOT NO.
TEL.
3.
NO. OF BEDROOMS—
DEN YES_ NO
4.
GARBAGE GRINDER YES
NO
5.
SHOW DIMENSIONS OF HOUSE
6.
SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
3-0
7.
SHOW DIMENSIONS OF LOT /' ro
/
�00
8.
SHOW LOCATION AND SIZE OF SEPTIC
TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
t' "- -
0 1 0
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE 8 /q Z71_
NAME OF APPLICANT Cjjpt;j, congt-Pl3etion CO -
LOCATION Lot #16 Raleigh Tavern
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X -Repair
GENERAL DESCRIPTION OF LAND- high
SUBSOIL: Clay_X,__ Gravel Sand
PERCOLATION TEST 7 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK.J.000 gallon capacity.
I
LEACH FIELD -()() lineal feet of drain pipe.
lf6lt* gravel under bed
William J. iscol , Engineek-1
Board of He lth
Common weal t h of Massachusetts
4. Massachusetts
System Pumping Record
System Owner
ScL-ruR-(—
Date of Pumping: /w /g/0 -
Cesspool: No [4' Yes
System Location
Quantity Pumped: 15—cj gallons
Septic Tank: No L I Yes I+—
System Pumped by: velredert 5ff&nhIae4 License
Contentstiansreirredto: GFeater Lawrence Sanitary Vistrict
Date:
Inspector
TOWN OFNORTHANOOMII/
-BOARD OF HEAL�4
Z"N 2 2 1999
Jill jot
8 F NORTH ANDOvE
ARD OF HEALTH
JUL -9
'96
- 17Z
0
0 R
F'j,
Jill 1w" V 119
lot
I k1#4
NO
in
sysiells Pumped W'!
It ..j
TOVVN F V -, �Ji)
S EM PUMPING RECORD
R —EIVED
EC
DATE: ry MAY 3 12005
M Y
0
TOWN OF NCRTAI ANDOVER
L I
LT P TM
FTOWHEALTH DE R ENT
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
u
DATEOFPUMPING: QUANTITYPUMFED: Spc> GALLONS
CESSPOOL: NO YES S PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ]z EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTIIER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
G. L. S. D
Lowell Waste
�LN Commonwealth of Massachusetts
15�01
CityfTown of
System Pumping Record
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other torffFs Tmay be used, but the
information must be, substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health opother approving authority.
A. Facility Information
1. System Lp n-: I
--catin_ Left side of house, Right side of house, Left front of house, Right front of house,
I—M r6ar of hooe, Right rear of house. Left rear of building. Right rear of building.
Address
Cityrrown
2. System Owner
Name
Address (if different from location)
CityfTown
State
'�� 'C '�3 a,< -
C)
Zip Code
Stat Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1-7 4(D
Date 2. Quantity Pumped. Gallons
3. Type of system: El Cesspool(s) 9-<eptic Tank F1 Tight Tank
El Other (describe):
4. Effluent Tee Filter present? [] Yes a --No
5. Condition of System -
6. System Pumped By:
Neil Bateson
Name
Bateson Ente!prises Inc
Company
7. Locati e contents were disposed.-
1G.L.S.D aste Water
R _. -4 —',
If yes, was it cleaned? 0 Yes 0 No
F5821
Vehicle License Number
-;�;" [6 _f 0
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
-C -N Commonwealth of Massachusetts RECEIVED
RE E ED
12
0
City/Town of OC C IV 0]
OCT 16 2012
0 System Pumping Record
TOWN OF NOffH ANDOVER
Form 4 L LT P TM WT R
HEALTH DEPARTMENT
DEP has provided this formlor use by local Boards of Health. Other.forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other,approving authority.
A. Facility Information
I . System Location: Left / Right front of hous qajo�f�5hou�, Left / right side of house, Left
,Qe 6
u. 'nf
/ Riht rear of I
Right side of building, Left Right front of bui ing, Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner
Name
Address (if different from location)
Cityrrown State��-\ 4a Zip Code
Telephone Number
B. Pumping Record- )17
1. Date of Pumping Date - 2. Quantity Pumped: Gallons
3. Type of system: Ej Cesspool(s) ETSeptic Tank E] Tight Tank
El Other (describe):
4. Effluent Tee Filter present? Ej Yes [Er No If yes, was it cleaned? E3 Yes 0 No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafiqn wher contents were disposed:
- I
N
G.LS Lowell Waste Water
Signitufe qt Haulej j Date
t5form4.doc- 06103
It
System Pumping Record - Page 1 of I