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Miscellaneous - 32 PADDOCK LANE 4/30/2018 (2)
32 PADDOCK LANE J 210/107.D-0097-0000.0 I i L 4 i } i I i Septic System Information D 32 PADDOCK LANE Printed On: Thursday,July 20, 2006 System ID: BHS-2006-0017 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No I Inspections: Inspected: Expires: Inspector: Status: 06/30/2006 Neil J. Bateson Passes Comments: Title 5 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 i Town of North Andover Health Department Date: 717Z4 Location: V 'eZ � (Indicate Address,if Residential,or Name o Check#: Type of Permit or License: (Circle) )0- Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:Undicate) Health Agent roti ,As 1665 White-Applicant Yellow-Health Pink-Treasurer COMMONWEALTH OF MASSACHUSETTS Ok F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVLU io1M SVev JUL - 7 2006 TOWN OF NORTH ANDOVER TITLE 5 LHEALTH DEPARTMENT OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 32 Paddock Lane— _North Andover_ Owner's Name:_Kevin Duffy Owner's Address: 32 Paddock Lane _North Andover,MA 01845_ Date of Inspection:6/30/2006_ Name of Inspector:_Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ Andover,Ma.01810` Telephone Number: (978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of 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: X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 6/30/2006_ 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 DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. r . r Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Paddock Lane_ _North Andover_ Owner:_Duffy— Date of Inspection: 6/30/2006_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined'please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Paddock Lane_ _North Andover— Owner: Duffy_ Date of Inspection:_6/30/2006_ 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Paddock Lane_ _North Andover— Owner: Duffy_ Date of Inspection: 6/30/2006_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6"below invert or available volume is''/z day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and 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.] No (Yes/No)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. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 R 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. Page 5 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 Paddock Lane_ —North Andover_ Owner: Duffy_ Date of Inspection: 6/30/2006_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ ` Has the system received normal flows in the previous two week period? _No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes — Were as built plans of the system obtained and examined? Yes — Was the facility or dwelling inspected for signs of sewage back up? _Yes_ _ Was the site inspected for signs of break out? _Yes_ _ Were all system components,excluding the SAS,located on site? _Yes _ 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? _Yes_ _ 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: Yes No _Yes_ — Existing information. _Yes _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of an_ distceis unacceptable)[3 10 CMR 15.302(3)(b)J Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 32 Paddock Lane_ _North Andover – Owner: Duffy_ Date of Inspection:_6/30/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4 Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_600_ Number of current residents:_3 Does residence have a garbage grinder(yes or no):_No Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter reading:_On well water,100'from septic_ Sump pump(yes or no):_No Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):,gpd Basis of design flow(seats/persons/sgft,etc.):— Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available:_ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped three years ago,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank Reason for pumping: Inspect tank&tees_ TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system Single cesspool_Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe):_ Approximate age of all components,date installed(if known)and source of information:-22 Years old,4/25/1984, as built plan_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Paddock Lane _North Andover_ Owner: Duffy_ Date of Inspection: 6/30/2006_ BUILDING SEWER_X_ (locate on site plan) Depth below grade: 24" Materials of construction: _Xcast iron _X_40 PVC_other Distance from private water supply_ well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _3"Cast iron thru wall,3"PVC in house with no leaks visible SEPTIC TANKS: X Depth below grade:_12"_ Material of construction:_X concrete`metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):^(attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth 4"_ Distance from top of sludge to bottom of outlet tee or baffle: 23"_ Scum thickness:_6" Distance from top of scum to top of outlet tee or baffle:- 8"-Distance from bottom of scum to bottom of outlet tee or baffle: 15"_ 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:Pumped septic tank.Inlet tee ok.Outlet tee ok. Depth of liquid at outlet invert.No evidence of septic tank leaking in or out. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Paddock Lane— _North Andover_ Owner: Duffy_ Date of Inspection: 6/30/2006 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(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Depth below grade _30"_ 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-Boa level&distribution equal.Evidence of carryover,pumped d-box to clean No evidence of leakage._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no): Alarm in working order(yes or no):" Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Paddock Lane_ _North Andover— Owner: Duffy_ Date of Inspection: 6/30/2006_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _ leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length:— X leaching field,number,dimensions:_1 field 20'x 40'_ overflow cesspool,number: innovative/altemative system Typetname 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: Number and configuration: Depth—top of liquid to inlet invert:_ Depth of sludge layer:— Depth of scum layer: Dimensions of cesspool:_ Materials of construction: Indication of groundwater inflow(yes or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Paddock Lane _North Andover_ Owner: Duffy_ Date of Inspection:_6/30/2006_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Well Head House To Well Driveway A Septic Tank 1 2 D-Box Ato1=22'6" Ato2=26'10" A to D-Box=3118" BtoI=15' Bto2=20'10" B to D-Box=31'6" Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Paddock Lane_ _North Andover Owner: Duffy_ Date of Inspection:_6/30/2006_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/25/1977_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 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._ � Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: fomes the �� • _Q Q computer,use only the tab key Address to move your cursor-do not use the return Cityfrown State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State !� 7��ode Telephone Number .B. Pumping .Record - -� (31. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes NoIf yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System um e �. Name Vehicle License Number Company 7. Location re contents vy�re dished: CIL a - Signature of ule Date http://www.mass.gov/dep/waterlapprovalt,/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 Tel: (978)475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 32 Paddock Lane, North Andover Owner: Duffy Date of Inspection: 6/30/2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. B teson Bateson Enterprises, Inc. 32 PADDOCK LANE JS-2006-0221 Project Detail Report Printed On:Mon Sep 79,2005 Project Name: GIS#: 7971 Project No: JS-2006-0221 Owner of Record TJ OGDEN WELL&PUMP µORTq 01,,... 4,� Map: 107.0 Date Submitted: Sep-19-2005 32 PADDOCK LANE or °; Block:— 0097 Status:_ Open — — NORTH ANDOVER, MA 01845 Lot: Work Category: Work Location: 32 PADDOCK LANE Zoning: Proposed Use: District: �sSACIN410 t, land Use: 101 Proposed Use Detail Subdivision 1 Description Well Construction Comments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2005-0053 Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: Well Construction BHP-2005-0279 Sep-19-2005 SIGNED OFF JS-2006-0221 Well Construction GeoTMS@ 2005 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 Ro. 0 , .\ COMMON'kA'EALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 617-292-5500 'ua 2 4 WILLIAM F.WELD TRUDY COXE Govemo: Secraary ARGEO PAUL CELLUCCI :DAVID B�STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A Q 1 CERTIFICATION raQProperty Address: ` � �` ��• '"` UI'(Address of Owner: Date of Inspection: r[— (If different) Name of Inspectors Ne i k � am a D �Pergved system ipecto pursuant to Section 15.340 of Title 5 (310 CMR.15.000) ,r Company Name: � t\ C 3l Mailing Address: �'�, rG• C)U�1 v Telephone Number: — 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 sposal systems. The system: _ Pl/ asses Conditionally Passes _ Needs urther Evaluation By the Local Approving Authority Inspector's Signature: L Date: The System Inspector shall 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: AI SYSTEM PA 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. COMMENTS: BI 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.megnet.state.ma.us/dep A Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address- ,-3 Owner: Date of Inspection: (� Bi 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 if(with approval of the Board of Health). Describe observations: 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 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 public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER 49 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS 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 the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspoction: D) SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: I 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. Yes No 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 availVble 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: 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: 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 11 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. (reviood 04/25/97) Psq* 3 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Pkc�_ ,_ L—V\• Owner: t��1A Me-- Date of Inspection: G Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following: Yes Pumping information was provided by the owner, occupant, or 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. The facility or dwelling was inspected for signs of sewage baric-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All 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 tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. T e size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the,proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J (zevieed 04/Z5/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INfORMAT ON Property Address:<3 949r, 1. V\ Owner: �, - Date of Inspection: FLOW CONDITIONS RESIDENTIAL: _ Design flow: d./bedroom for S.A.S. Number of bedrooms: Number of current residents:3 Garbage grinder (yes or no): Laundry connected to system (yes or no):�-s Seasonal use (yes or no):NO 1� Water meter readings, if a l ble (last two (2)year usage (gpd): Sump Pump (yes or no): N Last date of occupancy: « COMMERCIAUINDUSTRIAL: Type of establishment: ' Design flow: gallons/day 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 gate of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of iJ�.s cion: (yes or no) ~P If yes, volume pumped:. l�J��gallons Reason for pumping C TYPE OF STEM 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) I/A Technology etc. Copy of up to date contract? Other APPROXI TE AGE of oll components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: lyes or no)Eel (revised 04/25/97) Page 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � ��—� uvv Owner: Date of Inspection: I n G BUILDING SEWER: (Locate on site plan) Depth below grade:a Lf Material of conuru t iron_ 0 PVC loth`r (explain) nU 11 �rj�1 Distance if �ivate water supply well or suction line b �''�^ W C Diameter roQ P, Co eQ: tpo�nditipn of joints, venting, evidence of leakage, etc.) SEPTIC TANK:.. (locate on site plan) Depth below grade: c Material of construction: _concrete _metal _Fiberglass ,_Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: bottom of outlet tee or baffler DisEance from top of fludge to Scum thickness _ Distance from top of scum to top of outlet tee or baffle: t� r, Distance from bottom of scum to bolt m f o tlet tee or baffle: t `�e S �) � � �lZt�t j-'A. How dimensions were determined: Comments: (recommendation for pumping, cord' of inlet and utle ees or at�s, epth of(iqui4,levetl rXlatign too et ' ver, tr q_urra integrity, evid nce of leakage, tc.) v �\ yE rou Pao Dalt C4-0 K GREASE TRAP:V\0V1f- (locate on site plan) Depth below grade:. .,. Material of construction: _concrete _metal Fiberglass _Polyethylene �other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structure integrity, evidence of leakage, etc.) (ravtspd 04/35/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION (continued) Property Address: 3 �� J�—` LN, . �)O(_c. k Owner: "M�� Date of Inspection: V1- (\I - (?I? TIGHT OR HOLDING TANK" (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level:_Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:v (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: ( to if lev an distr' ution^' u I, ev� ence f solids carryover, evid nce eak a to or out of box, e ) d Jl C, O lJ Q C� LX P / C PUMP CHAMBER:jW1/\.0 ---�'r�1 (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/]5/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: %A Q-,f Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):U- -� (locate on site plan, if possible; excavation dot 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: 11 f 1 leaching fields, number, dimensions: t3y overflow cesspool,number: Alternative system: Name of Technology: Comments: (note conndjtion Qf;oil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOL$: 1J�Q (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:!L._—OAA (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 04/25/97) Page ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 a �C'��` �Jo6'A-A-�, Owner: t�USP Date of Inspection:^� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) P-) T a = L4 ( �J 3 _ Do /o �r (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater 9 Feet Please indicate all the methods used to determine High Groundwater Elevation: yObtain from Design Plans on record O`er bsewation of Site (Abutting property, observation hole, basement sump etc.) /� _ 1/Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how ,you established the High Groundwater Elevation. Must be completed) a (revised 04/25/97) Page 10 of 20 TFL: (508) 475-1-47-1 FAX: (508) 475-5-151 RATE-SON ENTERPRISES, INC. 1:xPwAling T Wow 1% Sowor Wnrs-Uptic Sysicros a Pumping Svivict: I VI Arbilk Road 0 Andover, Iviass. 01810 Title 5 Inspection Report: prPPOVty Addl'r~ss a ----------------- •T- C -CIA VA.0,C QWnsf; ------------------------------- ---- potP of Inspection: -� My reppVt pupt4ined herein does not con6LiLute a guarantee pf fj4tgrp usage 4nd the ftinction4lity of file exist:illU supL.ic PY0,091, Such report; issued herewitti is merely based upon ttty p0gorvotionaf dpd 1 Hereby disclaim any furLiter operaLiott of your current septic sy6Lem. � ,�/`//�/,�' `y- acs.•�.` Ile i l J . Iia LtSon liat.e5on EnLufp i5eb l.rtc . Yayt: l l of l l NUMBER NOR7N COMMONWEALTH OF MASSACHUSETTS BHP-2005-0279 North Andover FEE $125.00 Board of Health SsrcNUSti DUFFY REALTY TRUST& KEVIN P & KATHY J DUFFY, TRS NAME 32 PADDOCK LANE ADDRESS IS HEREBY GRANTED A PERMIT Well Construction This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires October 19,2005 unless sooner suspended or revoked. September 19,2005 Board of F'LE - - Health I" Town-of Aorth Andover Health Department Date: 7Z Location: � r.�...� (Indicate Address,if Residential,or Name of Busz�� Check#: ��./ Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ell Construction $ � ➢ OTHER(Indicate) Health Agent Initials 526 White-Applicant Yellow-Health Pink-Treasurer �. TOWN OF NORTH ANDOVER ` Office of C"OMM'UNITY DEVELOPMENT AND SERVICES e: v• HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y.Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX healthdept townofnorthandover.com www.townofnorthandover.com Well and/or Pump Application (Please print) DATE: 'IV-3 I— AGy� LOCATION to Drill Well or install a pump: 3-a LAH, Licensed Well Contractor Name and Company Name: L xe,. 46- C40-o-We J Contact Phone Numbers: Homeowner: AAu— ��� o� kZs n Address: 3 �o.�c�e(� v�•.t_ ��� c,.�.t..—. Contact Phone Numbers 7 e_ WELLS(to be completed at time of pump'test) Type of well: Use: Diameter of well: Size of Casing: Depth of bedrock: Depth of casing into bedrock: Seal been tested? Yes( ) No( )_ Date of test: Depth of well: Water-bearing rock: Depth of water: Delivers: GPM for: (how long) Drawdown: feet after pumping: hours at: GPM Date of Completion: - Signature of WellContractor PUMPS(To be filled in before installation) Name&size of Pump: Type: Size of Tank: Pump delivers: GPM Pipe used in well: Cast Iron_ Galvanized Plastic Sleeve used to protect pipe? Yes No Type of well seal: Date: Signature of Pump Installer Date water analysis report submitted to Health Department: �� Plumbing Wiring Inspector Health Department Representative C:\My Documents\Permit\Permit Applications\Well Application-2004.doc �� a" s. �e�c �_ 7:6. LCTWG 17 Al C k J fr5„. t, 3 C r tl. N.f4u7 t 0 RECEIVED El..E'�/,�"c`.='1'rdN S. ';' SSP - 2 2005 f� tat 41 C.ti+ AbW Vr TOWN OF NORTH DOVER.. VT oir HSE :r :.{� �3 i Cay ` 8 HEALTH DEPAP E U I I� E�/ a ta- Gti.i lv: 'srJ' i �rd'�7.Qi r 0`r D.QT G.j�►'�12d1.2�.,,�y� dt.j[> 11'SSQGIIS.T�� 1 iG G 4-1 t Y E G-r IS . Page 1 of 1 DelleChiaie, Pamela From: Grant, Michele Sent: Monday, September 19, 2005 9:59 AM To: DelleChiaie, Pamela Subject: 32 Paddock Pam, This man is coming down for his permit today. Could you please print out a permit for him. Thanks Michele E. Grant, Public Health Inspector 400 Osgood Street North Andover MA. 01845 978-688-9540- Phone 978-688-8476- Fax Add Emotion Icons to your Emails Click Here 9/19/2005 • a O i Y ` N � L.•t5�'�. �Y 2. b�"Z"'2'. �, *( :.y�. ��ki Y�'+"� l��. OO�>'y���Y"���"7 � .. • 2 r ` _o- WELL DATABASE ` ADDRESS: 14;vY , AGE OF 7f�ALL DR= i i WELL t l. IFERL/ ,7.T: —ViF=P 7:1 OF 'Wr�"T_L: T�HOF L: DRILTIED b. Dii0yy TYPEOFWA, SE`�RTYi ROCS = .A=A.LYA.z=DA=-- IHCi tif'NGANES:Z- Y N Y - =GEIRCY. Y N O CQ�ANT�: Y F��DATA-EA-SE ADDRESS: �. �- 4,4,-d' G .� AGE OF WT-.: ' DRILLERR -.WELL PERL=�. � 7 � �ii�� �- �`� c. �• . WELL PERLl�L i DATE: DEPTH 0F, WELL: - TY?E OF W_:_L: a-. DRIi..LED tb. DUG c. Li\FKNC WN TYPE OF WA-7--R BEARLti-G ROCK: WATER ANA YS_S DATE: INCH�NGA.NESE: Y N HIGH IRON: Y N OTr= CONTAI A–NTS: Y N TOWN OF Al . . �vjo\)-e-C SYSTEM PUMPING RECORD 1 DATE: 0 SYSTEM OWNER & ADDRESS SYSTEM LOCATION CIN (example:left front of house) '�N . ) DATE OF PIUMPING: - QUANTITi'PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIIFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEm PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CoNruvm TtUNS>t EPmm To: G.L.S.Q Lowell Waste Commonwealth of Massachusetts �• , Massachusetts System Pumping Record System Owner System Location �) U�--� uvv Date of Pumping: 6 Quantity Pumped: gallons Cesspool: No+j—] Yes [] Septic Tank: No [] Yes H-` System Pumped by: V4&4" License# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: Commonwealth of Massachusetts ,► �, Massachusetts System Pumping Record System Owner System^ Location 0 -6&C Date of Pumping: / by Quantity Pumped: � gallons Cesspool: No Yes L.) Septic Tank: No Yes System Pumped by: gctwort gila+7�ltlije,a License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector- YC dVN OF NORTH ANDOVER/ f30ARD OF HEALTH VIUN — 4 1999 V K LO-r PL&W Or. LAmpMA. ,. I I.1 �ICNARD F. k �.M t hISKI Ar�1D ASSOC I A'T�S,I�IC. til O rZT�-I A tipOUE_tZ � MA. 00 \LP iQ L o-r 2 `, Lo-r SA. 1.O ACO->=s± \ o , " O 4S LOT 1 �'� -- ----�--___ F-fl >=X I ST.✓will >1 ILL �L.=112.09 41 fn PROPE2TY LINE A. LINE OFFSETS �J.I�A \J dTA S►tOW1.� ONT{ IIS PL[aN &;FE SPEclFIGoLLY F02 TH6 ' 1ZEVls>^D 4-i(o-B4. >7ETE2M1►JdTIOP1 OF ZOMING t?6QUIR.EMENTS ONLY. LOCATION: 1--OT Z PADDoGIC LAwF- THE Dvva-L-ILILOCATED Ou LO 1=3. {(0 198 4 2 IS ►JOT LOCOTEO W ITN Q ZONE SCALE:{` 40 DATE: Fa % - „ , a`tH0- M4,;. . Gi (A2EtaOF100YE..Al2-FLOOc>) 4S �LA.VJ ILEPEtZE-NGE: ��� DAVIDA 9� SHOw►.t OM t-I.U.D. GI2MCOMn�Iu►►ITY 6EIn1G LOT 2 ON A PLAN {3Y ^� 1S 983►\10 250098 A �dTEO �u►-IE s VJEBBER ✓' PC-,&WV- c GEL I1Jds asso Io r>=s io N0.30757 h ' DATEC,• 2/7-Z/-77 A►.I� tZEcoczpc-p I"_ U qE^ j � I ►�E,2��C�tZTtF`� f*�� int: �1��1,1,. S��u�lu t D�1 fAts PLk\d 15 Lorq-r-v OSI T4=v12�J,�p ESSEX5 ►J.D. �� Cr �I„,v �O P�srsol+�� ��JD�tk COUt..iTY � �i _. a �c�J►��� �0IzT1-� gl�oc��rz. PLOT P is i rm Or L A,.m® I►.J V*J©lVrw AMPOVEP. , IIIA. 01C1-44RD F. IC AMIw5K-1 AI.ADASSOCIATEt> C. KI O 12--rN .A NJPO�/EfL A i S t \ f LOT 2 Lo-r 3,s. \ 1.0 \ x LOT I \�F� EXIST.DWELL ILL t�L.=172.09 n)2' fi Al 150.00' P1ZEPei�Ep FO►z : S.1� PRoPE�TY LINE QN17 STREET LINE Or-FEE-TS VA CD,d,TA S{-40W11 0r1TNIS PLAN AQ--E SPE G1FICoLLY FOe-TµE �EVtSED 4 1(v-S�}. I7ETEirMIAJdTipi,( OT= ZOWIIQG ONLY. LOCATION: Lor Z PAoflocic. LAws THE DWELLItJG LocA,TEo Ou Lo f 1=Ef3. 1(n 1 58 4 2 15WOT LOCATED W ITN tQ ZONE SGnL>✓=t`_ �40 DATE= - ,, , A`SH 0 �4 . /� (�►ZEtaOF 100 YE o 2>=LOoo) AS �LAU 2EFE2ENJGE : / DAYID A 9y SI-+Ow►.j 01,1 W.U.D. f:IzmcommuwITY /QwgjEINJG LOT 2 ONA. PLAN e)Y i WEBBER ✓; PS 9830. 250098 A DnT>=� �UN� F'LAN11� C .G>aLIudS A ds5o ItaTES I NO. 30757 L-2A.-rEC7: 2/7-Z/-77 AN.tp FEcocz L7ev I"_ J 9f: � � 1 �EtzEi�Ca=�T1F�i��jTH� 171��LL. 51lo1JlJ . T D�1 (►?tSPLq�I IsLocgtCC�OJTs�cGtzo,lJp ESSEX COUNI-rY i� ► ✓L_ ��v A,3-' P\55,,0LJjp�JD j1 of I'(SLQGZ\'(Ie? 12 f�r-ZOdI06- UIS OFT nr t DO �L \ LOT Z \ \ , l,.,OT $A, I.O lactz.Es+ � ON� 1500 GAL,SEPTIC T EX I ST.OWELL, \ 1 - P,�r roc k. l..a,►�E. 1 c� E L.E VA-r DE VT OF HSE. I Cn8 CoJ l Co8.88 �" n U f Lwy PIPF= NTo ICo8.43 ICo8.7� T1, h�1 1.ham E 0 u T O F'T I 8.18 1 6o8.70 („f " J U cz. � I�E D I r_.' P>O: 5A[ _ IN V. PIPE-LLA - v ICo7.8Co 1 8.42 _ 1NV. P►VE nU r D PDX I Co7.Cocj IC06•23 11iy r--t,3 a ir' P P . I Co 7.SO I &(5.0I. IV op.-r 14 A NJ C?O VE cC. MA. SGo, l-E t " � 40{ DA.�-E�Oprt142S,t�64 21cHa6eo N45 I atjC;, [�S ocla-rt=S :1:Nc . E.N61r.lEE�S � pp_cl-ItTEG'r'S � L.a.Nc7 P�aNtiE2.S �tia �,{ ,o ., �.e.•.,� � Board of Health SEPTIC STSTEM North An ver Masa. INSTALLATICK CHECK LIST .s� ' EXCAVATICW Og FAIL OTED 1 DI SAPPSUM, FAIL OK Distance Tot a. Wetlands b. Drains c.. Wen 2. Water Line Location 3. No PPC Pipe T 4. Septic Tank a. _Tees -_Length & To Clean 'Ont Cowers. ,s . b. Cement Pipe to Tank Oa Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks 10_ �''� b. All Lines Flowing Equal Amounts • c. No Back Flow 6. ' Leach Field or Trench a. Dimensions b. Stone Depth c. - Capped ids d. Clean Double Washed Stone 7. Leach Pits ` a. Dimensions' b. Ston�,�3'ep�th c. 9?;Ash Pads d. Teas eeCeraent Pipe to Pit - Both Sides O f. Clean Double Washed Stone 8. No Garbage Disposal 9. -Anal Grading Inspection 10. Barricading Covered SystemPIK ? 11. As Built Submdtted a. Lot Location b. Dimensions of System !" c. Location -with Regard-to Pere Test d. Elevations ` f e.' Water Table i 10/26/2005 09A7 FAX 19784590368 06DENWELLS 001/001 10--18-205 10:26AM FROM WILMINGTON PVMP SUPP 9786583557 P. 2 •1 `.0 TOWN OF NORTH ANDOVER Office of COMMLITY DE'VCLOPMENT AND,SERVICE'S HEALTH DEPARTMENT 27 CHARLES STREET NORTH-ANDOVER,MA,SSACHUSI TTS 01845 Susan Y.Sawyer.-RENSW 978.688.9540—Phone Ptjhlic Health Director 978.688.9542—FAX ealthde t com www.towuofnorthandovar.com -- WeH and/or•Pumy-Application (t'leasc print) DATE: LOCATION to Drill Well or install a pump: "�=2i► M -__ I acenxed Well Contractor Name and Company Name:"t,_cmc� (1K�_� Contact,Phone Numberar 21 R..omeowoer:_ v� �'�t*v► y� _/rt ii_ Address: Contact Phone-Numbers: WELIS'(to be eompkdrd at timo.orpump teail Type of wall: it use; S Ice D(amettr orwe11. ' Ile Size of cawn ;to Depth of bedrock Depth of tale;iwo bedroetu 9W been teateM )re+ `NQ( ) r>»tc M test•_ Depth ofwelL• d Water-beutsd roclt: _ #pth o!eatee�_ Dsli�en: GPM (►ow long) Dra•ckrwa� _ feet stta Pumld :� at.. —Grm Date or compledon:. re oontraetorr , PUNIPS'(To be fitted 1w befors iestallation) e� t Name&sae of-pump.. 1,1 W Typo- 4i,.•�,....,,�St �, ��v. c 5 h1htO of Tank: Pump delivom 1 GpM Pipe used id wnik�� Ctwt froo Gsiranized Plastic Site a-ed to protect pirps? Yea itlo_.Z_TAM of well seat. leers ©oto: Sitgolare of Pump laudY `• lh,to Wmer oualysig reswrt submitted to Health Departatbnt: PluutiDina Wiring j�oapeetue Health lk rgmcat_ IMI Repnseatattve C:1My I'�o0umoatc`PurmitlPe=11 Appiioffitioas1WeU Application-2004.doc OCT.113.2005 07:55 976((69920023 THOASTENSEN #3294 P.001 /001 ���l��l���J'1•jlf'hZ- .�JCC�fy7�l'f•C.��$I�, �l''y�(.'. 66 LITTLET(9N ROAD,WESTFORD,MA 01886 (978)692-8395 FAX(978)692-0023 1.800-649-TEST Report Number: 95740 Rc3i()rt Tate: 10/12/05 Gient: Sample Information: Wihningtou Pump Supply Kevin Dully PO Box.517 32 Paddock Ln. Wilmington MA 01887 N.Andover MA Sampled by: Client Date Received: 10/1 1/05 I)ate sampled: 10/10/05 Certificate oI'Analysis Tcct.Parameter LPA Limit Results T.1rti15 'Total C'olifortn(P) 0 0 perl00ml Fecal Coliform!!;.coli(P) Absent Absent per10Uml Arsenic(P) 0.05 0.006 mg/L Calcium Not Spec. 41.6 mg/l. Copper(S) 1.3 ==:0.02 mg/L Iron(S) 0.3 # 20.0 mg/L T.ead(P) 0.015 0.003 me/L Magneshun Not Spec. J2.5 mg/L Manganese(S) 0.05 # 2.0 rng/L POWNsium Not Spec. 3.0 mg/T. Sodium See Note 12.0 mg/L Alkalinity(S) Not Spec. 44,0 mg/L Ammonia-N Not Spec. 0.06 mg/l. Chloride(S) 250 122 mg/L Chlorine Not Spcc- <-:0.02 rng/L Color(S) I,5 # 17.5 CPU Conductivity Not Spec. 542 umbos/cm 1'luoride(S) 4.0 -O.I tng/L Hardness Not Spec. 155 mg/L Nitrate-N(T) 10 •=0.01 mg/T. Nitrite-N(P) 1 --0.05 mg/T, Odor 3 I TON pH(S) 6.5-8.5 # 6.1 SU Sulphate(S) 250 27.9 me/l. Turbidity Nut Spec. 8.7 NTLJ Sediment poNlneg neg Legends: (P)—Primary EPA Standard.(S)=Secondary EPA Standard,#--Execeds EPA Limit, IN 1'C=Too Numerous to Count,`—Background Bacteria Noted,'=Exceed Advisory Limit Sodium Advisory Limits,Mass-=z'20,NH=250. This water sample as submitted is considered SAFE to drink according to FP.A/PIIA guidelines. However,one or more parameters cxcecds secondary limits as denoted b the It sign.i, 'tot, Massachusetts Certification#MA018 Michael P-Car sun, Iin- Thorstensen Laboratory Inc. WILMINGTON PUMP SUPPLY, INC. PUMPING TEST Kevin Duffy 32 Padd6ck Ln No. Andover 10/10/05 • , JOB LOCATION DATE TIME Static GPM REMARKS • 9: 40 20 ' 10 1 10: 10 25 ' 10 10: 40 30 ' 10 11 : 10 30 ' 10 11 : 40 30 ' 1 12: 10 30 ' 10 12: 40 30 ' 10 1 : 10 30 ' 10 1 : 40 30 ' 10 stopped test I I Board of Health North bindover,Mass a SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT if 1 1 r i PPROVSD DATE DISAPPROVED DATE rovideds Reasons: -" itle V FAIL OIC 3g 2.5 The submitted plan must show as a minimums t the lot to be served-area,dimensions lot # abutters ; . location and log deep observation holes-distance to ties location and results percolation tests-distance to ties design calculations & calculations showing required leaching area location and dimensions of system-including reserve area Wdsting and proposed contours g) location any wet areas within lA0, of sewage disposal system or disclairer-check wetlands mapping h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer i) location any drainage easements within 100v of sesage disposal system or disclaimer-Planning Board files J) knosn sources of -rater. supply within '2001 of secage disposal . or disclaimer system (k) location of a proposed well to serve lot-1001 from leaching facility w1v (A1) location of water lines on property-101 from leaching facility d ) location of benchmark n) driveways L: garbage disposals 3 no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Otter elevations maximum ground meter elevation in area sewage disposal system s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans .eg 6 Septic Tanks (a) capac -150 of flow, water table, tees, depth of tees, f' access, pining b) cleanout t-e ) lot from cellar wall or inground swims ng pool (d) 25+ from subsurface drains :g 10.2. Distribution Boxes a) slope greater than 0.08 ,g 10.4 b) sump ' 1 1 b Subsurface Design Check List Pae 2 ' a FAIL M Leaching Pits Leaching pits are preferred where the installation is possible 1 Reg 11.2 a) calculations of leaching area-minimum 500 eq ft i 11.4 b) spacing ! 11.10 c surface a 2% 11.11 d� cover mat tial r e 2�a'2'x4"splash pad i f tee at bow g no been in pipe from d-box to pipe Leaching-Fields Reg 15.1 a no greater than 20 minutes/inch b area-mi.niwam 900 sq ft 15.4 construction of field 15.8 d tI) surface drainage 2 % 3.7 tt e) 201 from cellar wall or inground swLnidng pool Leaching 'Mches __ i Reg 14.1 a c cula s o eaching area-min 500 eq ft 14.3 b spacing ft min 6 ft with reserve between 14.4 c di.msn ns 14.6 d) cons ction 3-4.7 a sten 14.10 Y� surf as drainage 2% Do Slope a s ope y x = to be sho'$M b y/x 150 (to be showal s Reg 9.1 a) app 9.6 b) star -by power /( ,(1011111ton. ealllt of hiassacliusells 10 Massaciulselts aystem Pumping Record System Uwher System Location Dale of I'ulnping' r Quaiktity I'uuiped: gallons Cesspool: No 1:'es �_ Septic Tank: No Yes Sysieul 11totpped by: Voreoare 46Kiret#,"" license #__ CoMenls iransferrred to : 0l2atar L..arrrsslc_sgariltary Dlstric4 - Date: _.._ .__ - ------ -- ---- Inspector: 7 p� ..M••r■ R/ sd0►Ro RFHTH O pa . N +Y 3 1 095 SUBSURFACE SEWAGE DISPOSAL BY MM Address of property '3a p �C7(� ? owner's name Or Yt-d w.Vs7-e_ Date of Inspection 17s- PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of He lth. 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 sys em recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. � All system components, excluding the SAS, have been located on the s3,te. 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, dimensio s, depth of liquids depth of sl dge, depth of scum. V Y) �j k�-o C- wkcx- Q.,C .c.�,�+-VX- C�-O� W Z z o&-- b rec�t-h i �,t The size and location of the SAS on the site has %een determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS I'fI residential number of bedrooms number of current residents garbage grinder, yes or no 23 laundry connected to system, yes or no v seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Oh Well Last date of occupancy GENERAL INFORMATION Pumping records and our a of �nformati�on:Afa qC) _ oW"49� QS System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: , Ty a 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: &)O Sewage odors detected when arriving \at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B I/ SYSTEM INFORMATION continued SEPTIC TANK. r (locate on site plan) depth below grade: material of construction: ' concrete -metal FRP other(explain) dimensions• 5 " L x '7 ' S- - Sy`�.`7� ��0''` S sludge depth 71T" 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 3 „ 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 leakagg, recommendations for repairs, etc. ) ti OU ZZ7 2 C 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 Qf leakag ifito o out of box, recom�enc�ation for epairs, etc. 16 9A-k G O 2 u o O C d�-cOV2 v 2. PUMP CHAMBER: VADV\e- locate on site laA ( P ) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairg,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : y (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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions l FRE___ _ o`�c� ' X z'zv vizs overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, co dit ' on of ve et tion, recomme dations for maintenanc or repairs, c. 5�0, r ��,^ /�v S� S o-� c�r�,,1aG �L're U � V\. CESSPOOLS (locate'on site plan) : hone 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, recommendations for maintenance or repairs,etc. ) PRIVY: Y)Dv*\L (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, recommendations for maintenance or repairs,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' � l�v�s� W J t r A ��, sa, =o�yam '' qd n DEPTH TO GROUNDWATER V��cv� ti depth to groundwater method of determination or approximation: A 31 -r-C(M - L Vow, O C)KA . 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indichte yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? /V Discharge or ponding of effluent to the surface of the ground or surface waters? Al Static liquid level in the distribution box above outlet invert? A" Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? NRequired pumping 4 times or more in the last year? number of times pumped /" Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? /U Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? /V within 50 feet of a surface water? v" within 100 feet of a surface water supply or tributary to a surface water supply? 4 within a Zone I of a public well? /V within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? Nwithin 50 feet of a private water supply well? A/ 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Vo Company Name Bojes-ov,, Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Chec e: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is prov ' ed in the FAILURE CRITERIA section of this form. Inspector' s Signature Datef—��— Original to system owner Copies to: Buyer (if applicable) Approving authority FORM - SYSTEM PLILPL\G RECORD Commonwealth of Massachusetts TOWN OF NORTH ANDD ER/ BOARD OF HEALTH Massachusetts JLJN - 51,995 System Pumping Record vstem Owner SN,stem Location OjA a Date of Pumping: .J �C5� Quantity Pumped:( `� gallons Cesspool: No � 'es ❑ Septic Tank: No ❑ Yes -- System Pumped b}-: License #: Contents transferred to: - C— • T Date Inspector `t 1 i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED 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- 1. COMMENTS: CONTENTS TRANSFERRED TO: T