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HomeMy WebLinkAboutMiscellaneous - 312 FOSTER STREET 4/30/2018 312 FOSTER STREET — 290/104-B-D0 GMW.0 n ' t t SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: NEW < IR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT NO DWC PERMIT PAID? YES NO DWC PERMIT NO. 461aZ INSTALLER: IBJ r-u l e-L� BEGIN INSPECTION YES NO: EXCAVATION INSPECTION: NEEDED: PASSED 7 /7/76 BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES :, t APPROVAL TO BACKFILL: DATE: BY FINAL GRADING APPROVAL: DATE � / 1 FINAL CONSTRUCTION APPROVAL: DATE:7lZ BY 40 Commonwealth of Massachusetts City/Town of a System Pumping Record Form 4 �M 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 usin this form check with your local Board of Health to determine the form they use. The System Pumpi Recol'd�m`��u[„4t 6JE Ubm'Itt d to the local Board of Health or other approving authority. d A. Facility Information_ T 1. System Locaton_ g front of , 'ght front of house, left side of �I r' �hN tlT �` .8-HP, eft- rear of house, right rear of house, left side of building, right rear of bui ,urs M Tc�5442�c— 'E39— Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town State ,<�\ '/^ C Zip Code Te hone Number (� 3 B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [-Vo/ If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � Q� `c 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Locati re contents were disposed: .L.S.D. Lo II Waste ter I Signatu o a er Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I , O ��. Ail L crT 9 i LOT -T \Ati ( 4JNcu14W V-: 1 �T mac. flr.r► MAt�G- ' �, n= z�'ti rnL F. .:' T A O l V 41 �ef�Qow _ �r [S 7LF' -:1 ALA :�! kr•-MGV.�ji f <LZ \ T (E A!1 i &QeA MQ Vk-1 , P + x1<,,1r�►�-, ccx�r�,,rl 'JlJt3�SU¢F,�rC.G D15P��.SYS"r"Cnn �d►.l I - -- �[•'^t - �.r� C. i'r�t,2 LOT G7 1=oS�"E�2 ST. WO. l5.NG?v,/E:R 40 tDSTE: £; 18 "16 17f7L1h/1'- C. ,LIA1G'a�r t -J c— � ;�l� �': � l.15� ,c.NrxyvG-r2 �-r:, No. 4►,�rr��'�r� r.;�. . IN9TALT.A2 TT CHECK Ll gF I'OT ' APfOV�ED DATE DISAPPLOdED' D� .XOAVA710-t OK FAIL e�nsit- - I' a / - ✓ll SSL OK ` 1. Distance To E a. Wetlands i b. DrainsLI � c. Well ! 2. Water Line Locati 3•__No PPC Pipe___ Lolo �. Septic Tank - a. Tees -_Length & To Clean Out Covers _ f b. Cement Pipe to Tank - On Both Sides of Tank r / 5• Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Fqual Amounts C. No Back Flog 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends I d. Clean Double Washed Stone ?• Leach a a* cions r b. 7Sne Depth c. h Pads d. Tees e. Cewmt Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection �- 10. Barricading Covered System _ 11. As Built Submitted A. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations e: Water Table v 1 i C op - to Public Works I ' SUBSURFACE DISPOSAL- SYSTEM CHECK LIST $ ��sL NORTH ANDOVER BOARD OF HEALTH AP VED DATE PROVIDED DISAPPROVED DATE TIME REASON. Title 5 Reg. 2. 5 Fail OK The submitted plan must show as a minumum: he lot to be served (area,dimensions,lot //,abutters) (Planning Board files) location and log of deep observation holes-distance to ties location and results of percolation tests-distance to ties d)` design calculations & calculations showing required leaching area (e) ocation and dimensions of system (including reserve area) existing and proposed contours location of any wet areas within 100' of the sewage disposal system or disclaimer (check wetlands mapping) _ surface and subsurface drains within 100' of sewage disposal system or disclaimer location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) —( known sources of water supply within 200' of sewage disposal system or disclaimer location of any proposed well to serve the lot (100' from leaching facility) location of water lines on property (10' from leaching facilities) location of benchmark driveways garbage disposers no PVC is to be used in construction a profile of the system (elevations of basement, plumbers pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) maximum ground water elevation in area of sewage disposal system plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks Reg. 6r(b apacities - 150% of flow, water table , tees, depth f tees, access, pumping, leanout 0' from cellar wall or inground swimming pool 5' from subsurface drains C- t _Lv_ AT,t '7 .1 SCFE % _• t � • 2.fZ S�rKar IN IZ"0Z%V_ CC-Qr . i it t� '�?r>Ia.t F12 trTLA^.i e F i-9-r I o 14(a. ZQ : NOTE ' ALL ELE-VAZT IL'I`+ RAPER "Eu '4V `.R_i OF P� k q PLuPIPE C:Z DWE LL ! 151 . 1-7 �E PT 1 C TAN I< Z?J LET Z'PTIC 'IARIK 0UTL�T ISO, (4 le D t7 I ST �3 G x Tt�1 L=.T R D I ST 13ox aurt-E T !} 149 . 21 149 T Cao t { !3 oTTO M C?F (5c—C3 { r ' i t I ESSMANHOLES 'TLS wat4w 4 oF Fth1tsH q;zAr)E, FILL CONo1T1oWST Nov &,9?U CABI.0 � t3�t�t.�striG• PARF_R . � \, S=-OZ ted tri.--{r•- �y.!� 7. Ll i T CaOCl ,rt_ 451 ri I f - - J(-Q:'Sct4FMA.-rtC. ON01 R 'St'-M L 'i0Wr , SSE { F _ �► PLu�E� b P, NO'f£.: ALL ELC V&T%O N b TO IbO-r rOM Torr IctiT O� PII7 �lNdEt�'ty G `J 8 P-r►c. Tart v. Oof Lx-r t D piwra. Q01 ib �= D•�r tz. 130it OV r i.BT P4QF. RPM .oa CA"� W c7wG 45 �'1 8 Z 41 Z IF oos B B C D + E 4" PER.FOB.O�TED 131TUMINOV6 FIGE7_ PIPE. (CAPPED r.MDb) F MIN. �IYE ovr4Er F i� . - NOM- OE21=O"TQ9 PG2FoQATtyp L E M-44 I W CG Gat> � LIMIT LI Na r u PL& N Or- Lp-&c- ►imo DLD i No sCNLS �3ESIF,cia DA+A � C.�4L.CULv;1' �t3N5 SOIL P'E RCO1.AT I am -TEST Mo. t 2 ( 3 �� �T• � �S�# DAT i;. -$ , �a' —__ ..__. .___,y. -Top-P-LEV4TION BOTTOM-ELEvq-7 WON -- SATURATtoM -M%tAS. SCJ. 12" --09" DRO P-M1t4s. - 9" DR-OP-MINS. �+ IS, - -- - _ - � - - -- ---- - PERG RATE -MIW�/ITa. ,� SOIL PROFILE-DEEP PIT No. 1 3 4- 5 DATE TOP-ELE NATION � - - - - - - I I,,' �, 0 TOPSOIL (p S U BSOIL I PORE NT SOIL WATER TABLE S,p.NDVI wATCR TAZLE E-LEVATION 144- 0 BOTTOM ELEVATION � 144- 42 3 U I L D I NCr-TYPc 9\415"I N(-V - 4_B.R.,Op. -AISO_ _GAI..�Ui 4 I _400 CyAD F'LONN io0© CAPD FLaw X ►SO-/- 900 QPD � Ldp�� GAi..S F.P'ric TA.%qK �A�►-ttNG Ais�A t3 E D &C= G-PDTFww A SF/G-AL.= X12© SF B&D USE qOO SF r PITS TYP E Mv IRL. (-TyP.) _ j I DEWAI.L AR _ _ - SF x ( rALS.I SF GPD dOTTO zA :_- - _ SF -4 — GALLs4 SF a GPD S-cOT PIT LEACH NCi CAPAC-ITY _ _ _ _ _ _ _ GPD /'PIT _GPD FI,pW ;_ - GPD/PIT=—_ PIT$ RF-gD. USE` PITS +�ETJCHES DEWALL AR sP/LFx _ GALS /SF = GAL./LiW.FT• nT7'OM A GALS/SF = GAL LIN.F'-r. 0T E N C i-1 LEACHING CAPACITY _ _ - _ .._ _ G A L j L I A.'PT. GPD FLOW —L.F.'TRENcviEs Rc4b. USS L.F w 1 4 v r f i P� SUiZr-AC.E. Dispoc,4L- SYSTEM DESIGN of �T 1.10. L1,�0{ov�R�!�► . P2 EPA.��O F Ott P SA.!L I N C- . I GiZ,o.r,r� C G�L�nis.-z a►vo Assoc�A.-t-�s n ENC,IN���s atrti AczC-NITEC-TS { � r � Na�TN AH�o���Oc.s-��E. P,�sz.►c. \ll , .V' � ( �.,__ NORTN Atrt�OvLR,MA 01$45 i { Cununolls eall11 of t\fess"Chusetts Massachusetts s��raittrracrnr s��-i E—Oc a I 10n I Date or f'wnpliiu ��"—� —�� Qunutll;' f'umptds t ��� Cesspool: N'o I-es 1—j firnllr T"110 ht- Yes � ales D0 System Pumped by: License b: Contents traiisCerred to: �� 1 -S ' Urate Inspector R-CHPN�N BQAR '' 1 . 1 z GIN1 11 C;�b1���GtLd6.�b8� �$ .49,n?-ToM6-TED C3tT. fo1Ps STON'slab ,,, • t o• yG ��+ � a +"'fit` & .T ;'. �.Y� r :rr� s n. '. La ., '� s l�.�•v��A�: v 7J `. . '1 It, .:o:� `i -5• •. y co�.sE sA riaas .: -.. ;'4.t •-,=� .�: ,::� .�� �� .� ��.�. :��'.,,: _,� _;r��,�,. ;_ -. �r • + � } zo' x° 9 ¢} I i 3 ty � R CULOSS SE-CTlOtj OF LE-&cktm& 15�-D NO SC�6La t ! &LL ST o ME: 7-0 V5 E W S N ED Form No.4 f Town of North Andover, Massachusetts BOARD OF HEALTH •Ti11-- W 24 . 19 —gfi CERTIFICATE OF COMPLIANCE 9 This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ) by INSTALLER at North A dov r MA 01845 has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No.__ R4r, dated_Mav 1 5 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH v\V A I Town of North Andover, Massachusetts Form No.3 BOARD OF HEALTH Ot HORTH 1ti • O 9 V �''°�,r,o.••"� DISPOSAL WORKS CONSTRUCTION PERMIT .. ,SSgCMUSES Applicant �, NAME A DRESS TELEPHONE Site Location =3 , - JL L./,x • �4 Permission is hereby granted to Construct ( ) or Repair (van Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. t CHAIRMAN, BOARD OF HEALTH Fee Q D.W.C. No. y�— Address Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: " 31-8 I SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) 1�4 AbA a� kdusr DATE OF PUMPING:-1 '() QUANTITY PUMPED I So-0 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE YEMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: saL Z-sm COMMENTS: �t�aR 4""Uu" HEALT�',-��i CONTENTS TRANSFERRED TO: S. : Town of North Andover, Massachusetts Form No.2 o� MoDrM, BOARD OF HEALTH -A4Y ITL A DESIGN APPROVAL FOR b,,..••�"� ss"C"�5`` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant JAMES ��' �� Test No. Site Location Reference Plans and Specs.-`���L� • ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD HEALTH LFee6� Site System Permit No. I uILDI TES Ut- OA Y o _IJV I RIS T 14(,. 21;5 I . ZI.S ENG " Int , Z.2 *� 3`1, I' AZ' I41G,2� 3 20 M� Z N r N 4- L L ANG+ p l 3/Z i {1Frlow n 3 t!*, 1J6kJ Ti,60t 485 ��Tl;1z �TeE ET AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN AS PREPARED FOR DATE : JuLY Iq 199(0 SCALE: 1 ,!. e4 p' - MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS i 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 TEL (617) 479-3553, 373-57?) 0, Commonwealth of Massachusetts . Executive Office of Environmental Affairs s�F1r Department of , �oFaouF" �A�o" Environmental Prote�ribn� F. Weld ` �rudyCox* William Govsmor k Secretary Argeo Paul Celluccl David B. Struhs U.G Arnor C)mmissroner SUBSURFACE SEWAGE DISPOSAL SYSTEM INS CTION FORM PART A CERTIFICATION Property Address: —3 iA `s ' WO ✓p Address of Ovmen Date of Inspection: 3—clo — 9(0 (If different) Name of Inspector. —Tc, n r �q}-c y c r✓ Company Name,Address and Telephone Number- BATESON ENTERPRISES, INC. TEL:!.3081.1-5.1.1"4 Excavating-Water&Sewer lines-Septic Svstems 6 Pumping Service FAX:15081 475-5-4-1 1 11 Argilla Road . Andover,Mass.0 18 10 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: _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority L/�ails Inspector's Signature: Date: S CX0_576 The System Inspectors submit a copy of this inspection report to the Approving Authority within thirty(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 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 CMR 15.303. Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement 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. structurallv unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02106 • FAX(61.7)SWI049 • Telephone(617)292.5500 `0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address: 3).) FOSik r /q•. Jejt j..Qk Owner. R. Date of Inspection B)SYSTEM CONDITIONALLY PASSES (continued; Sewage backup or breakout 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 1(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 pipew. The system will pass inspection if(with approval of the Board of Health(: broken pipes)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the PO4Q 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. Z) 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 feet to a surface water supply 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 indicate&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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3I �vs�e s4 - Owner. _ Date of Inspection: Na- �� 'S r �"r`Q DI SYSTEM FAILS: have determined that the system violates one or 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 clogged SAS or cesspool. Discharge or ponding of effluent to the surface 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. 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. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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 II 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 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: r S'7 UvO A,-1 Owner. �� 3.q wig Q f p c f'�Q•✓ Date of Inspection: Check if the following have been done: (_-pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. Lthe facility or dwelling was inspected for signs of sewage back-up. L!The system does net teesive non-ow,i ry or industrial waste flew VThe site was inspected for signs of breakout. L"All system components, excluding the Soil Absorption System, have been located on the site. ,L The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. L,'I'he size and location of the Soil Absorption System on the site has been determined based on existing information or app ted by non intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �c / SYSTEM INFORMATION Property Address: 3/c� OST Q 51. Owner. MR . Date of Inspection: 3 FLOW CONDITIONS RESIDENTIAL Design flow: Ng moons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):- Laundry connected to system(yes or no)::jL Seasonal use(yes or no):A10 1 Water meter readings, if available: Urn c .r •�-_.,or f(/rr �,i<�o.� Last date of occupancy: g:�L--'I COMMERCIAL/INDUSTRIAL: Type of establishment: Design fiow:_gal►ons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: lyes 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: a�Nu 199 ,4,-54 System pumped as part of inspection: (yes or no)-)W-5 If yes,volume pumped: /So�� Qallolyy Reason for pumping: C_ _k S4,,,4,je o F-T.1..(z A-A Qn FF�.v_S TYPEOF�gYSTEM 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: 9 ! ( Ol-t�xJ�z IZl Sewage odors detected when arriving at the site: (yes or no)AAd (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 S1YSTEM INFORMATION (continued) Property Address: 3 f �D S7 (' -S? `– Owner. Date of Inspection: SEPTIC TANK-,.,— (locate ANK:-,I(locate on site plan) tr . Depth below grade:ho Material of construction: ycc6crete_metal_FRP_other(explain) Dimensions: Sludge depth: 5 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3'r Distance from top of scum to top of outlet tee or baffle: fS r Distance from bottom of scum to bottom of outlet tee or baffle: 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.) Se i h DA, keyj " A holkw A t T vttt� %wt k Sir i R Ol/o �� .a 14 Sn&La Q– R 1a.r (1:f2,z d k . GREASE TRAP S-v c (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 of scum to bottom of outlet tee or baffle: 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 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: 'a Owner. „.Q r r►c �te_n/ Date of Inspection: TIGHT OR HOLDING TANK/6i N,rF (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP —other(explain) Dimensions: Capacity: gallons 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 distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) box his r ' , 1 ✓.e S( d e,e ler 'A t,,✓d .[tr �le�✓ cl dar 1; i Fro g'F I, PUMP CHAMBER sU1nJ� (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 �° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 i F"1-2 S7 Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):-k� (locate on site plan, if possible; excavation 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: OOXy 5 /PAA F-,t overflow cesspool, number: C Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 301 Q A-1, F?,,nr_ _ CESSPOOLS:A&v- (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: 10A✓r (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, sigas.of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address 3 f-G,51e r �S7 Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wella within 100' .�i:JLJ4Y �014f A n Got A /4 —7eJ (' '� �l7 ' I L/ 0 , 5 DEPTH TO GROUNDWATER Depth to groundwater: y feet method of determination or approximation: fr►.JS c-°5 O� �!'ow., v s�¢ No L.i w IRR �/ 6-e�a.✓ S.,57/-c----� (revised 11/03/95) 9 4�1 t,/�- PLAN REVIEW CHECKLIST ADDRESS_3 /o'L ��TE.Z �� ENGINEER • Dox-,eEbAVC� GENERAL 3 COPIES STAMP L-� LOCUS NORTH ARROW SCALE CONTOURS PROFILE---� SECTION v' BENCHMARK - SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?,AL DRIVEWAY (Elev) WATER LINE L---' FDN DRAIN SCH40 TESTS CURRENT? SOIL EVAL ML)�5f 6e SEPTIC TANK / �� ,f 6100 MIN 1500G V . 17 INVERT DROP L GARB. GRINDER EDF) 25 ' TO CELLAR MANHOLE ELEV GW ## COMPS. D-BOX SIZE ## LINES .> FIRST 2 ' LEVEL STATEMENT L� INLET 1.47,6,_�'- OUTLET 147, 48 / (2" OR . 17 FT) TEE REQ'D? LEACHING MIN 660 GPD?,Z RESERVE AREA -'/4 ' FROM PRIMARY? 20 SLOPE 100 ' TO WETLANDS-L,::-'100' TO WELLS 4 ' TO S.H.GW '� (51 >2M/IN) 35 ' TO FND & INTRCPTR DRAINS —_ 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER-6•�_..F,ILL? (25 ' if above natural elev; 10 ' if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 611/100 ' ) ,/ SIDEWALL DIST. 3X EFF. W OR D (MIN 61 RESERVE BETWEEN TRENCHES? V IN FILL?--- MUST BE 10 ' MIN. 4" PEA STONE? L�-'VENT? (>3 ' COVER; LINES >501 ) BOT �fJ� + SIDE. 47- 0 X LDNG = TOT 44I L 6 6 y (L x W x ##) (DxLx2x##) (G/ft2) Copyright 5 1995 by S.L. Starr 107 Forest St. bO� FORM4-SYSTEAi PU112PIl�G RECORD .+ Middleton,MA 01949 _...,.._-Commonwealth of Massachusetts �t MassachusettsiO G, Eli"4119 System .Pum,Ping Record MY 30 I ► ,N �> 1A ari r ystemsystem Eocation ar od L�i Date of Pumping: 1 Quantity Pumped: ' gallons Ig Cess ool: o Yes p ' ❑ Septic Tank: No ❑ Yes ' System Pumped by: . ......................... .. ...........................•....•.....•........... License #: ................... < l �1.. Contents transferred to: Date Inspector Yfi L SI7� a��L i� �:•~� lei� ° ��, ,a: x 3 err t� a 3,:{ � � r � ��6 ���-: .�A � a a — M o,t ♦ � i � 1 IS mmm��������1�l�1f�r7 _ FIRAi �I4�7[�v mil 7 TOWN OF 0 EIV ED SYSTEM PUMPING RECO AUG 17 2004 DATE: TOWN T NORTH AND HEALTH DEPARTMENT SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example: left front of house) QVI� f7 DATE OF PUMPING: - QUANTITY PUMPED : L b CD GALLONS CESSPOOL: NO YES iSEPTICTANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D1 Lowell Waste