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Home My WebLink AboutMiscellaneous - 316 RALEIGH TAVERN LANE 4/30/2018 (2) Mvlk�j ��r� \�'��\� g Commonwealth of Massachusetts Title 5 Official Inspection Form ��z l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane ` 1 Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 23 2015 required for every _-July page. City/Town State Zip Code 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. RECEIVED Important:When A. General Information 15 20 filling out forms AUG 17 on the computer, use only the tab 1. Inspector: TOWN OF NORTH ANDOVER key to move your cursor-do notJohn DiVincenzo HEALTH DEPARTMENT use the return Name of Inspector key. Stewarts Septic Serive r� Company Name 58 South Kimball street Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License Number B. Certification 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: ❑ Passes Conditionally Passes ❑ Fails ❑ ed Furth valu tion by the Local Approving Authority IVesystem is Signature Date inspector shall sub c of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days o 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 DEP. 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. I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts _ z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23 2015 required for every Y page. City/Town 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: B) System Conditionally Passes: ® 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23 2015 required for every Y page. City/Town 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Dist box coroded around outlet inverts ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23 2015 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool E-1 ® 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 El 0 Liquid depth in cesspool is less than 6" below invert or available volume Is less than Y daY flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 July 23 2015 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. E] ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 ❑ ❑ 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 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 Forth:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts o- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is Y 23 North Andover Ma 01886 Jul 2015 required for 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23,2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: OccupiedDate 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 23 2015 required for every -July page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Stewarts Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site guage on truck Reason for pumping: Inspect tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is Y North Andover Ma 01886 Jul 23 2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 36 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is Y North Andover Ma 01886 Jul 23 2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure& sludge judge 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 2 outlet tees in place liquid levels good no leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,•'' 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23,2015 required for every Y page. 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: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other ex Iain (explain): ) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23 2015 required for every Y page. 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.): Leakage around outlet inverts very little solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is required for every North Andover Ma 01886 July 23,2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-20X40 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No Hydraulic failure no pondingno damp soils. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert layer Depth of solids la p Y Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts a v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23 2015 required for every _ Y � i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i Privy (locate on site plan): Materials of construction: Dimensions Depth of solids I Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 316 Raleigh Tavern Lane j Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 July 23 2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least,two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate 7whe a public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately V t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - g p y Not for Voluntary Assessments I 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23,2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 6'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Feb 7,1974 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Pulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high9 round water elevation: No pump in cellar dug hole 6'deep near dist box. No staining dist box no staining higher then outlet invert bottom of system 3' + above water table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 316 Raleigh Tavern Lane Property Address Ronn Coltin Owner Owner's Name information is North Andover Ma 01886 Jul 23 2015 required for every Y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® 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 • C� Io.iwm ��R•trED tiV PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/14/15 This is to certify that the individual subsurface disposal system received a ,SATISFACTORY INSPECTION of the: Repair of D-Box By: John Divincenzo At: 316316 Raleh!h Tavern Tavern Map 107A Lot 129 North Andover, MA 01845 T 1i I uan e of this ce ' scat 11 not e construed as a guarantee that the system will function satisfactorily. C Miclirele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com • North Andover Health Department [ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 316 Raleigh Tavern Lane MAP: LOT: INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 8/11/15 D-box DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic_tankproperly abandoned' ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ 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 ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX X Installed on stable stone base X H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) X Schedule 40 PVC Pipe Comments: ;P Map-Block-Lot Commonwealth of Massachusetts'FDY1 07.A0129 --- ------- -7BOARD OF HEALTH Permit No BHP-2015-0323 ----------------------- North Andover FEE P.I. $125.00 ----------------------- F.I. DISPOSAL WORKS CONSTRUCTION PERMIT John DiVincerizo Permission is hereby granted ----------------------------------------------- ----------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System-, at No 3-1-6-RALEIGH-TAVERN-LANE----- _bo)(--------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-201 03- Dated July 30,2015 COT -------------- ------------- - I-LE, --------------M------------------------------------ BOARD OF HEALTH Issued On:Jul-30-2015 ------------ ---------------------- - ------------------------- •,,gin°�� .•. Application for Septic Disposal System Construction Permit — TOWN OF TODAY'S ATE NORTH ANDOVER MA 01845 $250.00-Full Repair $125.00 -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 to move your epair or replace an existing system component—What? Ifi 151'e Isox cursor-do not use the return X Facility Information �� RECEIVED key. /� ��,-e c�.� Jay.-<_ r,.) L,.j Address or Lot# 106 City/Town TOWN OF NORTH ANDOVER roman 2.-*TYPE OF SEP IC SYSTEM'`: HEALTH DEPARTMENT ➢ Vstem, p Gravity(choose one) ***If pumattach copy of electrical permit to application*** ➢ ventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) / ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before D WC issuance) What is the Make? What is the Model. 2. Owner Information Name Address(if different from abo ) M �t City/Town State Zip Code Email address Telephone Number 3. Installer Information Name Name of Company Address / City/Town State _ ZipC e. Telephone Number(Cell(Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 _Application for Septic Disposal System - Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $250.00-Full Repair $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure 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 Subsurface Disposal Regulations for the Town of North n v . I derstpnd that until a final Certificate of Compliance has been issued by this o o He , th installed system is not approved. Date ' I li�atidn Approve�d : ( obrd of-Health Representative) w ` �.�) Name ` Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attacbed.? Yes No 2. Project Manager Obligation Form AttachedP Yes No 3. Pump System? If so,Attach copy ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received? Yes No MisSing: 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) G. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit-Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by `� ' (Engineer) Relative to the application ofi; `yi zc_el P6 (Installer's name) And dated rigina ate Dated _j, �1 j�� o ay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer,I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally,this is the first(VS inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK(or e-mail to: healthdel2t@townofnorthandover.co from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, gnificant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by theehomecowner. general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: Tod 's D e) 7J k,/ ( ame—' Print) a — igne �L\ Commonwealth of Massachusetts City/Town of No andover System Pumping Record y` 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: jt 31u �on the computer, � e use only the taby key to move your Address cursor-do not No Andover Ma use the return — _ — key. City/ own State Zip Coda 2. System Owner: ccs Name ream Address(if different from location) City/Town G State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping at 2• Quantity Pumped. llons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System r-- Name Vehicl License Number Stewart's Septic Servic Company ` 7. Location where contents were disposed: Plant 20 So. Mill Bradford Stewart's Pre-treatment , Ma 0183 Signature of Hauler Date Signature of Receiving Facility Date ^c•03/06 System Pumping Record•Page 1 of 1 N -- - —..- - --.xv`r arrr+.r�.�c�cr+.s�ecur+.�-a..s.:+.�n.r�w�•:�r:.Yc� -•�-»..�.:"�c-�. .... .,� ... x,�..� .. .. u-4.�,......- - i. r. _ _ .....-_ -......wr..Y.-a r.`.� - .._w._ _ � ,.._ _� f v ,t IV ll # -r-,.A. { . _,► > YIuM, 7ral;L7 r � vr.. ¢4' O.4•rS�B+iiv 1-1r0eF'�:.,.L.s.� !� � 11 1 � Emory r rr,/ C ¢ yC. Yr.•E. 140.4 •v�Fo...•L,r t:,r+ � L 0 7- 41 ` , fir « OF ERNET \� \ a L ' 2u� W4 25 74 00 Gee v,&r. Tit e- a! 1!' 1 iv 7 1i e c- 19 �' � _... ._ �+. ...... ..._ �..,, J� jN�l�f�LF Ci �!'CO.+3/J ru,l.- r 1 l"LH•LI s ' � �J�� }7~ -/�dC�arc Il f i!•�-'�____ •'' _.+t� - - ' I e r o� [. /�•��_-__�`�o•n ��:1-SIG ��,v�. t %,44 -2- 4) 342 { i 1 rte. /-`r.��• � - 1 r��• � _ .�1' .may.�yF.. r . '`�'{� �� F i s t r 1 - ,� j t a �. �� t �� -�= �� --�� - Commonwealth of Massachusetts City/Town of N . Pfndover W° 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 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. RECEIVE® A. Facility Information JUN 15 2015 Important:When filling out forms 1. Sy m Location: TOWN OF NORTH ANDOVER on the computer, ^A # WEALTH DEPARTP EtgT use only the tab ern • key to move your Ad res cursor-do not nn ' use the return key. City/Town State Zip Code 2. System Owner: Ro(� Cbi n Name '. rermn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 6/1 1. Date of Pumping Date — 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) MSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: O�j -- 2 6. System Pu By: i Vehicle License Number a ' tic eany 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1