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TOWN OFj\ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Date: C1 t,) -
Homeowner: R., . (I
Pumper
Street so Address:
Phone L-09,8% covl Phone : 1,2 1
Nature of S-arvice:
observations:
Description of Work:
Comments:
Routine
E mergency
Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy,Grease
Roots
Other (Explain)
Tr,.v,�; n�:
13 ic-- i
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Sherwgod Homes
Lot 2b2 Mark Rd.
APPLICATION FOR SEWAGE D1SPCSAL INSTALUTION �4_56' Drisco 1)
HEALTH DEPARTWNT - NORTH ANDOVER, ASS. V_105 4 'd
I hereby ma e WfW��ion for a permit for a sewage disposal installation at
Lot 2� P 4 1 will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 21o. I will install a con-
crete septic tank of C -Ai- 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 I Y -b " —lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4!1 (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.
I further agree not to cover aliZ 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 musj,be submitted withapplication.
JUL 14 1961
DA TE
turey'of Atplicant
I hereby issue the above permit for tfie" B6aXd-.Wf Health o'�,e Town of North
Andover, Massachusetts.
JUL 14 1561
DA TE
-gignature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DA
vo�
Percolation Test 2, min. Soil:Gravel (Fill) Signature of �) pecting Officeir
Garbage Gri�der No
July 11 1961
Miss Mary Sheridan R. N.
Health Agent
Board of Health
North Andover, Mass.
Dear Miss Sheridan:
An examination was made as requested in order to determine the
suitabilitycf the soil for the subsurface disposal of sewage on the
proposed Mark Road building site (Lot #28) of Sherwood'Homes,, Inc.
The land in general is high.
The subsoil in the area was of gravel content (fill) and a 2 -minute
percolation test was conducted.
It is recommended that a 1,000 gallon concrete septic tank be
installed together with 180 lineal feet of drain pipe.
Very truly yours,
co
WJD:hd
2
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS,
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1. NAM .`V.V—X ".'A* �66 DATE q o a
2,, ADDRESS LOr NO. TEL*
3. NO. OF BEDROOM . . . . . DEN YES NO.
4, GARBAGE GRINDER YES NO*
SHOW DIMNSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPEPTY LINES
7. SHOW DIlvENSIONS OF LOT
8, SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
lo.. SHON LOCATION OF BROOKS, STREATZ., DITCHESs IEDGE OUTCROP, ETC,
11. SHOW DISTA14CE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIOM SHOULD BE READ CAREFULLY.
William F. Weld
Goornar
Tirud X6
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..r.ta,y%EA
David B. Struhs
Commissioner
0
Commonwealth of Massachusetts 00 B9
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address. VAd"dfr4es-s of Owner:
Date of Inspection: (if different)
Name of Inspector:
Company Name, Address and Telephone Number:
I�Aqdv.(v J", �%�C- , /t o hip
/11
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
XPasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
0
The Sys�tem I pect r shall sub i copy of this inspection report to the Approving Authority within thirty (30) days of completing thiis
Deck
inspectio . 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 rep rt to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CA4R Is.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES: 9
One or . more system components nh/to replaced or repaired. The system, upon completion of the replacernent or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined"'\, explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltrationor i�hk failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conformin septlilank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street 0 Boston, Massachusetts 02108 0 FAX (617) 556-1049 9 Telephone (617) 292-55M
%D Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 14 14
Owner:
Date of Inspection: Dlzl's
8] SYSTEM CONDITIONALLY PASSES (con
Sewage backio—r/lbut or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 9. #-
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 fee! to a surface water suppl-y or tributary to a
surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
— The system has a septic tank and soil absorption System and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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 -
D] SYSTEM FAILS:
I have determined that the system viola Yeo r more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
— Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
Discharge or poncling of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: pk
Owner: 3 6 1z ((- (L
Date of Inspection:
D) SYSTEM FAILS (continued):
— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
— Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
— 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
— Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: N At
The following criteria apply to large systems in addition to the criteria above:
i
The design flov,- of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
— the system is within 400 feet of a surface drinking water supply
— the system is within 200 feet of a tributary to a surface drinking water supply
— the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone Il'of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 6
CHECKLIST
Property Address:
Owner:
Date of Inspection: C 0
Check if t, ng have been done:
Pu ping information was requested of the owner, occupant, and.Board of Health.
u
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
'ing that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
AVBuilt Plans have been obtained and examined. Note if they are not available with N/A.
T
he faci ity or dwelling was inspected for signs of sewage back-up.
e system does not receive non -sanitary or industrial waste flow
The site was inspected for signs of breakout.
system components, excluding the Soil Absorption System, have been located on the site,
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
Th ze and location of the Soil Absorption System on the site has been determined based on existing information or
ximated by non -intrusive methods.
�Xro`
—The facility &,� ne, (and occupants, if different from, owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection: NZISCO
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ' allons
Number of bedrooms: -3
Number of current residents:
Garbage grinder (yes or no):46
Laundry connected to syst�q (yes or no):Y—
Seasonal use (yes or no): &I .
Water meter readings, if a6lable:
Last date of occupancy: V
COMMERCIAIJINDUSTRIAL:
Type of establishment:
Design flow: allons/day A, 'r
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
OTHER: (Describe)
Last date of occupancy:_
GENERAL INFORMATION
PUMPING RECORDS and source of information:
j V -e AA14
System pumped as part of inspection: (yes o no)—
If yes, volume pumped Ions
_,�,�a 1,
.1ol
Reason for pumping: t -A-
TYPE09WSTEM
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: i -Ie
.0 1
Sewage odors detected when arriving at the site: (yes or no) —A
.' /I
(revised 8/15/95)
r4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
30 SYSTEM INFORMATION (continued)
Property Address: .1401& )V4 lk/ 'A'A_1 0 � V e__
Owner:
Date of Inspection: seal
SEPTIC TANK:yl
(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal _FRP —other(explain)
Dimensions: X -A 2
Sludge depth: � ;A I
Distance from iop of sludge to bottom of outlet tee or baffle:_�L'
I of
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: 4y
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
A-10 '�'/5tf 0 'C
GREASE TRAP:—
(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal _FRP —other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom oi 5rurn t- bottom of outlet tee or battle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
)k/ t�
Property Address:
Owner:
Date of Inspection: 0—f 9 co 0 -
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal —FRP —other(explain)
Dimensions:
Capacity: Ions
Design flow:_________gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distr;but;--r ;, equa!, evidence of sohd, carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
�- T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Al
Owner: 171 v
Date of Inspection: C
SOIL ABSORPTION SYSTEM (SAS): qoo 11�
(locate on site plan, if possible; ex��on not required, but may be approximated by non -intrusive methods)
if not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:.
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: � A /) ,
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 8/15/95) 8
or " / P/7,Q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspec tion:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater:_L:±_feet
method of determination or approximation: 190 ev )y R
J 1-4 /FZ e-141"zona e4l'# r --ex 6 9
(revised 8/15/95)
9