HomeMy WebLinkAboutMiscellaneous - 33 SULLIVAN STREET 4/30/2018 (2)n.)
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MAP # D LOT # �._ _.._._ ........... .
PARCEL# _ STREET.-._.-_._._._.._ ............. ........ .......... ....... __........ ..... .......... .....
CONSTRUCT.I_Q.N__..APPROVAL.
HAS PLAN REVIEW FEE BEEN PAID? YE5 NO
%, 7
PLAN APPROVAL: DATE %//� Z=APP. BY.._.._�LZ.....
DESIGNER: z2_ Lam, PLAN DA'I'E.___!,b. Z._
CONDITIONS
FORM U APPROVAL:
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:
APPROVAL TU ISSUE YES NO
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL S NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL _YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE•.//:J.k
BY: X ,
WATER SUPPLY: TOWN
ELL
WELL PERMIT 7 9 _
DRILLER._
.............��._1_Lr.../..fILG..S......_._.._...............
_..
-htUV=D
7/7
WELL TESTS: CHEMICALllN1L
.._.�._
BACTERIA
I
DATE APPRUVED
6 7/e,
BACTERIA
II
DATE APPROVEll..__...____„_...___._..._._
'.. COMMENTS:
FORM U APPROVAL:
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:
APPROVAL TU ISSUE YES NO
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL S NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL _YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE•.//:J.k
BY: X ,
IS THE INSTALLER LICENSED? YES' NO
_._.
TYPE. OF CONSTRUCTION: LW fiE!'AIR
NEW CONSTRUCTION: CERTIFIED PLOT PLnN REVIE=W YFS 110
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT NO. INSTALLER:
'
..
BEGIN .INSPECTION YES 0:
EXCAVATION . INSPECTION: NEEDED:
PASSED BY
CONSTRUCTION INSPECTION: NEEDEDa�___
AS BUILT PLAN SATISFACTORY:
APPROVAL TO BACKFILL: DATE: BY__—_
FINAL GRADING APPROVAL: DATE �� / BY-
___---
%����,L✓�_.BY_
FINAL CONSTRUCTION APPROVAL: DATE:
Commonwealth of Massachusetts RECEIVED
City/Town of APR 2 2015
System Pumping- Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use- by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Inforfution
1. System Location: a front of ho , Left / Right rear of house, Left /right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address �Q� K
City/Town ` State
2. System Owner.
Name
Address (if different from location)
City/Town
A
('C1v 1a -,
a
Zip Code
state Zip Code
C;
Telephone Number
U -91C
B. Pumping Record,-, — `�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system:❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Ea 0 If yes, was it cleaned? ❑ Yes ❑ No,
'5. Condition of Sy tem:
c� ► V
6. System Pumped By.
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Loc5-0kM*4:ikre contents were disposed:
Waste Water
F5821
Vehicle License Number
Date
-C�A(S--
t5form4.docr 06/03
System Pumping Record •Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
a System Pumping Record
Form 4
�M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before 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 tpumping date.in _
accordance with 310 CMR 15.351. t -.
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
use only the tab
37 SULLIVAN STREET
key to move your
Address
cursor - do not
NORTH ANDOVER
use the return
City/Town
key.
VQ 2. System Owner:
STEVEJASKELA
Name
nam
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
❑ Other (describe)
8/26/13
Date
❑ Cesspool(s)
SEP C 9 2013
TOWN OF NORTH ANDOVER i
HEALTH DEPAPT.MtE-NT
MA 01845
State Zip Code
State
Telephone Number
2. Quantity Pumped:
® Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II
Name
X SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler
Zip Code
1000
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
8/26/13
Date
Signature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
Commonwealth of MassachusettVEDs
City/Town of I 1
System Pumping Record APR 0 3 2006
w„
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health.. The VS m-Pt�rnpit�g= cord must
be submitted to the.local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer. use
only the Y b key Address
to move our
cursor - do not
frownit
use thereturn Cy Stat Zip Code
key.
2. System Owner`
Name
Address (if different from location)
Cityfrown State Zip Codec
Telephone t% nb)&(rl j/��-
B. Pumping Record
1.. Date. of Pumping Date 2. Quantity Pumped: r
Gallons
3. Type of system: ❑ Cesspool(s)Septic Tank ❑ Tight.Tank
❑ Other (describe):
4: Effluent Tee Filter present? ❑ Yes U/No If yes, was it cleaned? ❑Yes ❑ No
5. Condition of System: r
6. System Pumped B
Name
i� l Vehicle License Number
Company --
7. Location where contents were disposed::
http://www.mass'.govi.
t5form4.doc• 06103
91s/
shtm#inspect
Date
System Purimping Record • Page 1 of 1
Commonwealth of Massachusetss
: Massachusetts
System Pumping Record
stem Owner Location
rIt - I Me) E r, ) St "ph 6n imary Hnine
1, UI'IIVjrI .'! ISystegn
)! .:Uliivjn -t
Form 4 -- System Pumping Record
67; tiORTH AMD
TO
JAN 6 20M
Iorti, A,J, e, r. I -IA 11645 Writ th ,ndk,VcI tA- h16
Type: Emergency Routine
r7--L-
Cesspool: W Yes Septic tank: Yes I
Date of Pumping. 9 Z- Z Quantity Pumped: Gallons
System Pumped By: 6 wind River EnwV11madl, ac Permit #:
Contents transferred to:
�J/ 101
Contents Disposed at: V
Daft:
of System/Other Comments
Pumper
Dep Approved Form 12/.07/95
'A, f..
"A
C.'U"RRIER
SEP,rlc,&. DP.,-,u-N*,SERV-rCE
107 FOREST 'L
0 , CtT; N4MX)L?TrN7 NIA 0949'
(978) 774.41? -,2
—S' I �PL T VNFA 7 G
'orw 4. 3ys�m PUNI'k-3
NW-QACKLI$ET-TS
SYSTEM L06,
y
AO (4 $ 'e
DATE OF F-IjMpING 7 -Ll --2-Y PUM?-ED:
CESSPOOL NO • Y -Fs lynC I Tri ANK No F
sysm\j PLPAPem DY:-LTJPp
Ic a
Col""--ENTS 'rp-ANSFC- RRZ-D
DATE:
lcj WbqT:,Le '000E TI -}-,o
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 33 Sullivan Street _
_ North Andover_
Owner's Name: _Stephen Delmarco
Owner's Address: 33 Sullivan Street
_ North Andover, MA 01845_
Date of Inspection: _3/24/2006_
Name of Inspector: Neil J Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
RECEIVED
APR 0 3 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMIENT
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
"Fai
Inspector's Signature: ate: _3/24/2006_
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.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _33 Sullivan Street
_ North Andover
Owner:_ Delmarco
Date of Inspection: 3/24/2006_
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 Sof 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _33 Sullivan Street-
-
North Andover
—
Owner: _Delmarco_
Date of Inspection: _3/24/2006
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: _33 Sullivan Street _
_ North Andover
—
Owner: _Delmarco_
Date of Inspection: _3/24/2006
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 cloa�ed 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 '/2 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 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.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _33 Sullivan Street _
_ North Andover _
Owner: _Delmarco _
Date of Inspection: _3/24/2006_
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
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _33 Sullivan Street
_ North Andover–
Owner: _Delmarco _
Date of Inspection: 3/24/2006_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): �4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 _660_
Number of current residents:
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, well head >100' to septic system _
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 2004, 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: _14 years old, 12/9/1992,
as built plan _
Were sewage odors detected when arriving at the site (yes or no): No
Page 7 of 1 i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Sullivan Street
_ North Andover
Owner: __
Dehnarco_
Date of Inspection: _3/24/2006
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _30"
Materials of construction: _ cast iron _X_40 PVC _other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.) 4" PVC thru wall. 3" PVC in house, no
leaks visible
SEPTIC TANKS: X
Depth below grade: _16"
Material of construction: X concrete _ metal _fiberglass _polyethylene
_oxher(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: 3"_
Distance from top of sludge to bottom of outlet tee or baffle: 24" _
Scum thickness: _3"
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: 18"
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 corroded on top.
Outlet cover broken, replaced cover with d -box cover. Depth at outlet invert. No evidence of leakage. _
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: 33 Sullivan Street_
North Andover_
Owner: _Delmarco_
Date of Inspection: _3/24/2006_
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: _X_
Depth below grade _2' 10"
Depth of liquid level above outlet invert: 0"_
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):_D-box level & distribution equal.. Evidence of carryover, pumped d -box to
clean. No evidence of leakage. Cover broken replaced it. _
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: _33 Sullivan Street_
_ North Andover _
Owner: _Delmarco_
Date of Inspection: _3/24/2006_
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
X leaching chambers, number: 3
leaching galleries, number:
— leaching trenches, number, length:
— leaching field, number, dimensions:
overflow cesspool, number:
innovativelalternative 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. Camera inside of chambers thru outlets in d -box,
no liquid at inverts. _
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: 33 Sullivan Street_
_ North Andover—
Owner: _Delmarco_
Date of Inspection: _3/24/2006
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 —010
A to Tank = 34'9"
A to D -Box = 42'9"
B to Tank = 37'
B to D -Box = 44'10"
Page 1 L of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Sullivan Street _
_ North Andover -
Ower: _Delmarco _
Date of Inspection: _3/24/2006_
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: _4/12/1990_
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 test pit data on design plan _
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: 33 Sullivan Street, North Andover
Owner: Delmarco
Date of Inspection: 3/24/2006
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.
1
Nei4Beson
Bateson Enterprises, Inc.
Town of North Andover Massachusetts Form No. z
940"rif BOARD OF HEALTH'
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
t
Applicant T•
est N 0
At
Site Location` �
A
'Reference PlansSpecs
c s.
and S 44,
t:
{'fry x ENGINEER DESIGN
DATE
J,,
Permission is granted 'for an individual soil 06t:.Sewaki disposalsystem to be installed
UB -
in accordance with ieiulations o Board of
V
CHAIRMAN, BOARD OF HEALTH
A
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I NORSE ENVIRONMENTAL SERVIMCESItNt.
s 3 Pondview Place
TVngsboro, Mass. 09879
TEL. 649-9932
CERTIFICATION OF SUBSURFACE SEWAGE
DISPOSAL SYSTEM INSTALLATION
I� STEVEN ERIKSEN A Registered Sanitarian duly
licensed by the'Commonwealth of Massachusetts, License Number 886,
and working as an employee for Norse Environmental Services, Inc.
certify that I have visually inspected the construction of the
individual subsurface sewage disposal system at the referenced
location and hereby certify that to the best of my knowledge and
belief all work has been performed and completed in general
compliance with the terms of the permit and in general accordance
with the plans approved by the local Board of Health. Furthermore,
all construction appears to comply with the provisions of Title V
of the Massachusetts Environmental Code (310 CMR 15.00) and all
applicable local regulations.
LOT NUMBER: 4
STREET ADDRESS: Sullivan Street
TOWN: North Andover, Ma.
DATE: 12-9-92
SIGNATURE:"
SEAL - 13 STEVEN
ERIKSEN
NO 886
Ji �• ,
F�F� SANI\PQ\P
AS -BUILT SURVEY
Lot 4 Sullivan Street
No. Andover, Ma.
1" = 20'
12-9-92
Owner: James Graphoni
Installer: Tim Melvin
Location Elevation
Top Foundation ...... 180.18
Foundation Outlet... 177.13,
Tank Inlet .......... 176.33—'
Tank Outlet ......... 176.10"
D -Box Inlet......... 176.04"
D -Box Outlet........ 175.88,,"
Chamber Inlet #1...175.55
it if #2...175.51
#3...175.52
Chamber Bottom .....173.46"
N IF
iUN K
16 (' -ro LEA6+1
CAAMZS-f{5
OT 4-
SULLIVAN STREET'
Heavy Duty
C'.) Submersible
and Effluent
F -OR 5.0-H.
FkEG7ARD1r.I(7 Pu MP
O►J L -o -r 4933-41
Av4Cy )S Rgp,V'ry
Sewage
Pump
Pump Specifications
Size: 2" Discharge, 13/4" Suction Opening
Impeller: 2 Vanes, Molded Material with
Pressure Vanes on back side
Seal: Mechanical Type with Ceramic and
Carbon Faces
Pump Body: Cast Iron
Motor Housing: Cast Iron
Hardware: Corrosion Resistant Stainless Steel
Power Cord: 15' of 14/3 SJTO
Suitable For: 1500 Liquids
Standard Equipment: Equipped with Legs for
116" setting above bottom of Sump Basin
Page SEA
Pe40
abody BaRnes
Models
SE411
SE421
Size
2"
Handles
1-1/2" Solids
Motor Specifications
Model SE411 - 4/10 HP, 115 Volt, Single Phase
Model SE421 - 4/10 HP, 230 Volt, Single Phase
Single Phase: PSC (Permanent Split Capacitor)
Completely Oil -Filled and Overload Protection
I n IVotor
Motor Speed: 1700 R.P.M.
Shaft: 1/2" Diameter 416 Stainless Steel
Thrust Bearing: Sall
Radial Bearing: Sleeve - Permanent Lubrication
Page SE -2 Models
SE411
SE421
I1.D5—
A.375��f
n
R
2.00 NPT
DISCHARGE
6+ 20
3+ 10
U.S. GALLONS
PER MINUTE
LITERS
dbPER MINUTE
Peabody BaRnes
651 North Main Street, Mansfield. Ohio 44902
Phone: 419/522-1511
r- - - - - - --
-idt
20 40 60 80 100 120
75 151 227 302 378 454
Form No. 1197-963
C
SUCTION
TOTAL HEAD
MTRS FT
50
15
i .
I
}
Performance Curve
t
Submersible Wastewater and
L
Effluent Pumps
Models: SE411 and SE421
12
40
Motor: 4/10 HP, 115, 230 volt,
+_ . i. �
Single Phase, 1700 RPM
_:
::71—
Peabody Barnes Inc.
-i-•- --4 -.A
1 j
91
30
}
T,�
6+ 20
3+ 10
U.S. GALLONS
PER MINUTE
LITERS
dbPER MINUTE
Peabody BaRnes
651 North Main Street, Mansfield. Ohio 44902
Phone: 419/522-1511
r- - - - - - --
-idt
20 40 60 80 100 120
75 151 227 302 378 454
Form No. 1197-963
C
PITS
MIN 660 LEACHING
EXCAV 2x EFF W OR D
GW MIN 4' BELOW BOTTOM
12"-48" STONE SURROUNDING
MANHOLE/PIT
BOT + SIDE x LOAD = TOTAL
(L x W x #) (2 x (L+W) x D x #)
CHAMBERS
COVER >3 FT - VENT
FIELDS
MIN 900 ft LEACHING PERC RATE FASTER THAN 20M/IN GW MIN
4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE?
4" PEA STONE? DIST LINE SLOPE .005? >3' COVER - VENT
SCH 40 MIN 12" COVER ,L x W = T x LDNG > DESIGN FLOW?
DOSING TANKS AND PUMPS /0,00 6.
DIMENSIONS X 7-6-A/ X .Sa �! = PUMP CAPACITY gpm
L W sf D Vol.
DISCHARGE SIZE, G DISCHARGE RATE DISCHARGE TIME
gPm $
MANHOLES TO GRADE (,/ ALARM SEP. CIRC. IN-"` GW _i (Min . 1' below �� q• 4G,
inlet) HWL IdZ.93 LWL CHECK VALVE_I,,:,,- BLEEDER HOLE L---- MANUAL
OP. SWITCH j/'
I PLAN REVIEW CHECKLIST
ADDRESS ��A �/ /j�CJ ENGINEER
GENERAL
3 COPIES STAMP L/ LOCUS !/ SCALE &,-" CONTOURS
PROFILE 1/ SECTION I/ BENCHMARK �-'� ELEVATIONS SOIL
& PERC INFO WETS. DISCLAIMER WELLS & WETLANDS
WATERSHED DISTRICT DRIVEWAY/ WATER LINE(/ DRAINS
RESERVE AREA i/ SCH40 SLOPE
SEPTIC TANK
MIN 1500G. t/ .17 INVERT DROP &,--- GARB. GRINDER(+200% EDF)
25' TO CELLAR MANHOLE TO GRADE 1-� ELEV GW
D -BOX
# OUTLETS 3 FIRST 2' LEVEL STATEMENT INLET
OUTLEVZD (2" OR .17 FT)
LEACHING
100' TO WETLANDS 6'� 100' TO WELLS 325' TO SURFACE H2O SUPP
35' TO FND & INTRCPTR DRAINS 4,� 4' TO S.H.GW 2% SLOPE
4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25' if
above natural elevation; 101if below)
TRENCHES
6
MIN 660 SLOPE (min .005 or 6"/1001)_
SIDEWALL DIST. 2X EFF. W OR D (MIN 61)
TRENCHES? IN FILL? MUST BE 10' MIN.
>3' COVER? - VENT
IS RESERVE BETWEEN
BOT X LDNG + SIDE X LDNG = TOT
(L x W x #) (G/ft2) (DxLx2x#)
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DATE
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE lP�. PERMIT # DATE RECEIVED
APPLICANT iyf�i l/t.� ASSESSOR'S MAP
ADDRESS
ENGINEER
ADDRESS
PLAN DATE
CONDITIONS OF APPROVAL:
APPROVED 1�
DISAPPROVED
PARCEL #
LOT #
STREET
REVISION DATE zl'l2fAa
FIRING 7-0 �E vcf�4a s D�4 3,57
se�-p /'L�� /2���T w �� N /NSTi4GLL�
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: J Cr R i F c:
5 �/
LOCATION: Assessor's Map.Number
- 1 4
Subdivision F,+ ,/� A
Street -S L. LLiUAnJ `:
Phone 6.t, -7--/3 ?-
Parcel
Lot (s)
St. Number ;
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Health Agent
Comments
Date Approved
Date Rejected
.Date Approved
Date Rejected
Date Approved e
Date Rejected
Public Works - sewer/water connections rLJ 0 C� I
P 1
- driveway permit PD +a4 �-t,.a, , 011f2.l " QLo.,�,
...,,,J{✓-�Vi�i
Fire Department)
Received by Building Inspector
�r27z
Date
M
0
2
E
o`
LL
X01
,-
W
0
LU
0"
Q in
01
t
.. ,...
? � Dt� artment of En iron ental Management/Division of Water Resources
WATER WELL COMPLETION REPORT
WELL C • , GEOGRAPHIC DESCRIPTION
Address
N SW of
(feet) circle)
City/Town
Well owner (road)
r
A ress 6 Y6 N S E 11' of
S�,Y�iJ+v d y / (mi in tenths) (drelel
JILI
Board of Health permit: yes no/] intersect. W .
(ro dJ
WELL USE WELL DATA
Domestic R) Public ❑ Industrial ❑ Total well depth '7 6 ft.
Monitoring ❑ Other Depth to bedrock ft.
Water -bearing rock/unconsolidated material:
Method drilled '
Date drilled""-�' oZ Description --�!
CASING Water bearing Anes: /
1) From �To
Type
Length, ft. Dia(.I.D.)in. 2) From To
3) From To
Length i to bedrockn j it.
w Gravel pack well: dia.
Protectif a s1654 Screen: dia.
Grout.❑ Other Slott' length- from_to
STATIC WATER LEVEL f
Static water level below land surface/ft. Date r"
WELL TESTS� ��
Drawdown) aQQy ft. after pumping-0—hr. , min. atgpm
f
o e u R covery—ft. after hr. min.
0
LOG of FORMATIONS ENTS
Materials From To
1 i �
Driller
Mass. Regi i
Firm
Add, JP
City/Town
',
� r
Si na r s r er s re isle wel _ rll/ �
Please prior firmly BOAR OF HEALTH COPY
NUMBER FEE
THE COMMONWEALTH OF MASSACHUSETTS $25.00
..TOWN.------- of ------ DIORTH--MD0V.E.B.................................
Skillings & Sons
Thisis to Certify that--------------------------------------------------------------------------------------------------------------------
NAME
26-9 -Proctor Hill Road, Hollis., ..N.H-------------------•---------------•---------
ADDRESS
IS HEREBY GRANTED A LICENSE
For -----------------Well... ]?]:i11-ixi.g.._2.e.r it------Lot...-#4--Sullivan---Road--------•------------
.................. -................................................................................................... ---------------------------------------------------
---------------------•--•-•-•••---------••------------------------------------..............--•--------------------•--•----•---------- ....................................
This license is granted in conformity with the Statutes and ordinances relating thereto, and
expires --- -December 31, 1992
................................................. unles!,Ooner suspended. o ke
t1
n
....... July .... 4 ............................. 19--9-- -----
FORM 433 HOBBS & WARREN. INC.
� ivw wra�vprSrw�w ��.swaa vwwv sr�p rsrw
66 UTTLETON ROAD WESTFORD. MA 01M (508) 692.8395 FAX (508) 692*023
14Mx649-TEST
Report Number: C-sks-6322
Client:
Mr. .Roger Skillings
Skillings and Sons
269 Proctor Hill Rd.
Hollis N71 03049
Sample Taken By: SIBS Staff
TEST PAR4.METER :
Total Coliform (P)
Calcium
Copper (S)
Iron (S)
Magnesium
Manganese (S)
Sodium
Potassium (S)
Alkalinity (S)
Ammonia
Chloride (S)
Chlorine (total)
Color (S)
Conductivity
Hardness
Nitrates(as N)(P)
Nitrites(as v)
pH (S)
Odor (S)
Sulphates (S}
Turbidity
Sediment
Report Date: July 28, 1992
Sample Taken At:
White Birch Constr.
Lot 4 Sullivan Rd.
I. Andover MA -
On: July 27, 1992
CERTIFICATE OF ANALYSIS
EPA Max
RESULTS
UNITS
0
0
Per 100ml
itio Limit
34.1
mg /L.
1.3
0.05
mg/L
0.3
<0.01
mg/L
No Limit
5.2
me/L
0.0.5:0.9
i
mg/L
it 20
11.9
mg/L
No Limit.
2
mg/L
No Limit
82
mg/L
No Limit
0.04
mg/L
250
19.5
mg/L
Not Spec
1.1
mg/L
15
15
CPU
No Limit
252
umboslcm
No Limit
107
mg/L
10
0.31
mg/L
1
<0.01
mg/L
6.5-8.5
8.3
SU
3
2 ,
TON
250
15.7
mg/L
5
1.31
INTU
pos/neg
neg
SIT=Nor Tested, #=Value Exceeds EPA STD, TNTC=Too Numerous to Count
*=Background Bacteria Noted, "=EPA Advisory Lim-;+--
=Exceeds
imit=Exceeds EPA Advisory Limit
(P)=Primary EPA Standard, (S)=Secondary EPA Standard (may affect
aesthetics of drinking water i.e. taste, color, etc.)
This water sample, as tested, :s considered SAFE to drink according
to EPA guidelines. However, one or more of the parameters exceeds
EPA standards as indicated by the (:i) sign.
Massachusetts State Certified
Te5tino Laboratory #MA048
Michael P. Carlson, for
Thorstensen Laboratory Inc.
--------------------------------------------------'-------------------------------
.Y" ...ALC 12 ,9.` 8 Lll .... .�� ;..... . , .. :. _ i,u� ,:•:1 + _ � '�. :::� "`cc M
a
BOARD OF 111:
j
Commonwealth of Massachusetts RECEIVE®
City/Town of
System Pumping Record AUG 2 7 2007
Form 4
s• . TOWN
OLF, ORTHPN rER
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
DEP has provided this form for use by local Boards of Health. H A may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
OZA�
'r" 1 n
Address +fi
Cityrrown
2. System Owner:
Name
Address (f differen
City/Town
13 Ju Rdy oy- , c /V_
State
n
from location)
Zip Code
State R&6' r? :�fip ode
Telephone Number
B. Pumping Record R Y ( I ��--
1. 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 2-9-0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:��
6. SystempuT�ped 6
Name
Company
7.
t5form4.doc• 06/03
ere cont!`ts w disposed:
Vehicle License Number
System Pumping Record • Page 1 of 1