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HomeMy WebLinkAboutMiscellaneous - 356 REA STREET 4/30/2018 (2)f r I Lot & Street 3qe 8eyl S—i . Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# 119 Plan Approval- Date: 1 Approved by: Designer: , Plan Date-... Conditions: Water Supply: Town _ Well_ _ Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date- Approved Bacteria H Date.Approved Plumbing Sign -Off Wiring Sign -Off - Comments: Form "U" Approval: Approval to -Issue: YES NO Date Issued By: Conditions: Final Approval - All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOA OFi HEALTH APPROVAL: DATE: APPROVED B SEPTIC SYSTEM INSTALLATION Y , Is the installer licensed?UYESI_ NO - Type of Construction: NEW_a New Construction: -Certified Plot Plan Review YES --Floor Plan Review YES NO Conditions of Approval from Form U YES NO -Issuance of DWC pe 't: - YES NO DWC Permit Paid?VEL.AYES NO . - --DWC-Permit # Installer. io � p _-- _ Begin Inspection:_ YES NO _Excavation Inspection: _ -Needed: — Passed:___ -_Construction Inspection: Needed: As�BuilfPlan Satisfactory: YES: -_ Approval of Backfill: Date: Final Grading Approval: Date: $y: t O Final Construction Approval: Date: o By: -Z -. Certificate of Compliance: Approval Date: l Commonwealth of Massachusetts RECEIVE® City/Town of NORTH ANDOVER V 2514 o System Pumping Record4 Form 4'a4't{9*`�r,tfitviNT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. System Location: Address NORTH ANDOVER Citylrown 2. System Owner: ream Name (0 A4ea S� W\ Address (if different from location) City/Town Ma State State Telephone Number B. Pumping Record 1. Date of PumpingDate 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. ,System Pumped By: `()rvcR met c\k Name Stewart's Ser)tic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradfoi SignaturqAf Hauler Signature of Receiving Facility Zip Code Zip Code oo Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No JM1s1101 Vehicle License Number Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 ` Commonwealth of Massachusetts ?� City/Town`of NORTH ANDOVER MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by Iocal.Boards of Health. T e Ss eurriptng Re m' rd mu; be submitted to the local Board of Health or other approving au ority. 4 A. Facility Information Important: When filling out forms on the . computer, use only the tab key to move your cursor - do not use the return key. W� 1. System Location: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT - Address City/Town`—`✓ � State Zip Code --- - 2. System Owner: name Address (if different from location) C ity/Town B. Pumping Record 1.>Date.of Pumping 3. Type of system: ❑ ❑ Other (describe): State --- Zip Code Telephone Number ---- - Date -- 2. Quantity Pumped Cesspool(s) ptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Mao / If yes, was it cleaned? Yes r ❑ • 6 Condition of System: 6. Sy em Pumped By: ame- - Vehicle License Number '- Company 16t, 't, 7. Location where contents were disposed: J �AW, Si ature of Hau Date------ --- ---- - http://www.mass.gov/dep/water/ provals/t5forms.htm#inspect t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Pmt # ---goo - DsUSekddd AppMM Utt1r' �bCmkw AS -BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 WILLIAM I SCOTT Director July 30, 1998 Mr. Ben Osgood, Jr. New England Engineering 33 Walker Road North Andover, MA 01845 Re: 356 Rea Street Dear Ben: This is confirm that the Board of Health, at their regularly scheduled meeting on July 23, 1998, voted to granted the following variances: a) Reduction of the groundwater offset between the bottom of the soil absorption system and the groundwater form the required 4 feet to 3 feet. b) Reduction in the offset from the foundation wall to the soil absorption system from the required 20 feet to 17 feet. If you have any questions, please do not hesitate to call the Board of Health Office. Sincerer, Sandra Starr, Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Jul -28-98 06:59A Paul D. Turbide, PE/PLS 508-465-0313 P.02 PORT INGINILM111ING Civil Engineers & Lend Surveyors One Harris Street Newburyport, MA 01950 (978)465-8594 July 27, 1998 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 356 Rea Street Dear Sandra, Please find the following continuing deficiencies for the above referenced site. General Information * No designer's certification statement is shown on the pian. Distribution Box * No inlet baffle/tee is specified in the D -box. 232(3)(a) Leaching Facility • An existing retaining wall is shown on the plan 13' from the leaching bed, elevations or types of construction are not provided and therefore it is not possible to determine compliance with the regulations. If the retaining wall is concrete then it will have to meet 15.255 (a) -(g), if it is not concrete it must be made impervious and the details of this must be specified. 255(2) If any questions or comments please feel free to contact us. Paul D. Turbide, PE/PLS Town of North Andover, Massachusetts BOARD OF HEALTH 19 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant y r�A'�G,� Test No.: 8vr� Site Location Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absoprtion sewage disposal system to be installed in accordance with regulations of the State and the Board of Health. BOARD OF HEALTH Fee 0/'? Site System Permit No. SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES S60.00/Plan lk REVISED PLANS: YES DATE: 71a�/A9 DESIGN ENG ;EER: 0,5600-6 When the submission is all in place, route to the Health Secretary 7-6- 70 --P6,�r' 7%aI%9 8 e NORTH 1 0 tt�ao ie h0 SSAcHUSEtI(°, Applicant � L;/ NAME Site Location— ADD ocation Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT AJC ji! C i ADD C-7) YT LEP Permission is hereby granted to Construct ( ) or Repair (/'�) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No._ !2134 / 0O Fee S CHAIRMAN, BOARD OF HEA H D.W.C. No. 102-9 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: LOCATION: 3 4,E LICENSED INSTALLER: SIGNATURE: CHECK ONE: REPAIR: V/ CURRENT INSTALLER'S LICENSE# sir Vc)• ,AA1G)z)i 14 w TELEPHONE# NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes N, �.i Foundation As -Built? Yes--''� o Floor Plans? �Y s No Approval Date: NEW ENGLAND ENGINEERING SERVICES INC ,11j! ? 6 June 24,1998 Sandra Starr, Health Administrator North Andover Board of Health Town Hall Annex North Andover, MA 01845 Re: 356 Rea Street Dear Sandra: Enclosed are 3 copies of a septic system design for 356 Rea Street. This design requires the following local upgrade approvals: 1. Reduction of the groundwater offset between the bottom of the soil absorption system and the groundwater from the required 4 feet to 3 feet. 2. Reduction in the offset from the foundation wall to the soil absorption system from the required 20 feet to 17 feet. This plan also incorporates the use of a polly barrier at a distance of 10 feet from the system with a 2:1 slope beyond the barrier. This also needs to be approved by the Board of Health. na The last time we spoke you mentioned that this item could be put on the Board of Health agenda for July 9, 1998. Please confirm this date with me so I may prepare to attend. If you have any questions please do not hesitate to call. Yours truly, 6 (fo Benjamin C. Osgo2 r., EIT President 33 WALKER ROAD - SUITE 23 - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 ,r. c. 4� � f 7`�.. �1,�ty. "' 00 I� ..�: y �...J •�` •�. �. ry ;r —_ .. - -- ----'—�`----- — — ��--------'moo _ — �- i� .� , _ _. 'Y.. -`r r''� o, '� ,. 1 ., . ^� ` _., C ,. � .,__ ��t:, L �� ,. .__; .. __..___._ . _ l �� � A .� ,r, �, \� _ _, .. ,, . ,. .. g, . � fi ,.. ,� Y ..� � � � ._ �_. ,, ,,, _ - --- *'- � —_— —� 1S _`.. _.. pis— _ __ _ _ . _ . _ _.. i'_ �� �`� �.. �� _ � - — yam_ ._+� t ...—._ _ �` _ :� _ _. . , , ' �i �\ �—__— _ _ _ _ ___ _ _..._�_— _—.__ _--. ___ .. _ _ _ _—_gyp\j—F-�_ .`� � . i ... �. T f � V Y --- � —------....- -�---- — --- ��--_.----- �..�- ~—. .�. 1.. -- — -- - .� �� ,.. � --- �--- `� ' � �.— - - .. _ -� -, _ .-(' b __ �_ t _ _ � ` ? � _ �.._ � r ' -� -- - - --- --- - -- -- - - - � -s.�- � _ � ' _� . _. � --- -,. � � � � ... � , �� —S �,c � � � � Y � C y i � � Date: August 4, 1998 Town of North Andover, Massachusetts BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ( X ) by John Soucy, at # 356 Rea Street, N. Andover, MA, has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit # 986-1, dated July 28, 1998 . The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health SS/cjp Revised: 7/20/98 r FROM P,. C. TANGARD AUG 04 'go t 3: o? a;w TOWN OF NORTH ANDOVER SF,WAOE DISPOSAL SYSTEM INSTALLATION CERTIFICATION AUG. 4.1998 1:31PM P 1 PHONE NO. : 617 334 0115 P . 0 2 ;.'f J"he undersigned hereby cerrify that the Sewage Disposal System ( ) eonsrructed: O)e) repaired; by located at was installed in conformance with the North Andover Board of Health approved plwi, System Design Perzriit ��L-/. dated 7 r2� with an approved design flow of gallons per day; The materials used wer6 in conformance \vith those specified on the approved plan, the systerA was installed in accordance v ith the provisions of 310 CMZ 15.000, Title 5 and local regulatior�g, and the fa.oal Srading agrees subsrantW]v with Qu approved plan, All work is accurately mpresentcd oti the As -built which has been submitted to the Board of Health. Bed inspection data: _7 Final inspection date: Installer: /_�, Design Engin G ? TOV Cl �'%IORTH AP'OOVER/ ,�.•�� ��=; �c�,r rte AUG -- 4 t,U , 0 VF> FROM : R. C. TANGARD AUG 04 '9e t3: 09 AUG - Q TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTENI LNSTALLATION CERTIFICATION AUG. 4.1998 1:31PM P 1 PHONE N0. : 617 334 0115 P . 0 2 n<. The undersigned hereby certify that the Sewage Disposal System { ) constructed: ><O repaired: by located at was installed in conformance with the North Andovor Board of Health approved plaza, System Design Perzriit / dated 7/-.,-,,r _. with an approved design flow of VYZ3 gallons per day, The rnaterials used wer6 in conformance with those specified on the approved plan: the systerA was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the anal grading agrees substantially with Elie approved plan, All work is accurately represented on the As -built which has been submitted to the Bo:xd of Health. rr„. Bed inspection date: _ Final inspection date: T.nStgllaa Design 7co-tor� -� � i Date: A Date: 5 r AS -BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUSPLAN NEW ENGLAND ENGINEERING SERVICES lk INC July 20, 1998 Sandra Starr, Administrator North Andover Board of Healh Osgood Street North Andover, MA 01845 Re: 356 Rea Street Dear Sandra: Enclosed are five prints of a revised septic system design for the above referenced property. The plans have changes to address the comments from Port Engineering as follows: 1.The deed reference has been added. 2. Bouyancy calculations have been added to the plans. 3. The grading in the profile has been adjusted to show 9" of cover over the septic tank. 4. An inlet tee has not been specified. The inlet tee is not required on a pipe entering the distribution box when the slope is less than 0.08 ft/ft. The slope on the pipe is 0.01 ft/ft. 5. Stone is specified under the distribution box. 6. The poly barrier has been extended to the corner of the house and the depth has been extended to make the stone retaining wall impervious. A note was not added regarding the orifice size on the pipe since all contractors use pipe with holes already drilled to a standard size that meets title 5. The variance items still need to be addressed. I will be at the Board of Health meeting on Thursday July 23, 1998 to discuss these items. If you have any other questions please do not hesitate to contact this office. Yours truly, eBeninrCOsgood,., EIT President 1 33 WALKER ROAD - SUITE 23 - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 JUL 14 July 8, 1998 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 356 Rea Street Dear Sandra, Enclosed find the "Checklist for North Andover Septic System Plans" for the above- mentioned site. The following is a list of all the `Problem' areas and deficiencies Port Engineering has found. General Information • No deed references are shown on the plan. 220(3) • No designer's certification statement is shown on the plan. On-site Soil and Groundwater Review • Only one perc test was performed. 101(4) This requirement was probably waived by the BOH representative on site. Setback Distances 15.21.1 • The setback from the cellar wall is only 17' less than the required 20', a variance from this requirement has been requested. Septic Tank PORT• No buoyancy calculations are provided and the tank is below the water table. 221(8) INGINEERING• The cover over the septic tank is less than the required nine inches. According to the dimensions shown, the top of the septic tank is less than 2" below the ground. 228(1) Civil Engineers & Land Surveyors One Harris Street Distribution Box Newburyport, MA 01950 (978) 465-8594 . No inlet baffle/tee is specified in the D -box. 232(3)(a) • No stone is specified beneath the d -box. 221(2) Leaching Facility • Less than the required groundwater separation is specified, however a variance has been requested. 212 (a) & (b) • No orifice size is specified for the system. 251(8) • An existing retaining wall is shown on the plan 13' from the leaching bed, elevations or types of construction are not provided and therefore it is not possible to determine compliance with the regulations. If the retaining wall is concrete then it will have to meet 15.255 (a) -(g), if it is not concrete it must be made impervious and the details of this must be specified. 255(2) If you have any questions or comments please feel free to contact us. Sincerely �r Carlton A. Brown, PE/PLS CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS The following is a checklist that incorporates all Title 5 and local regulations for septic plans Name of applicant: GALL' Plan Date: O i 4 Revision Date: Name ofDesignerjQi'-w s ,Agls�t,D Date of Review. 7 I, 9g Propertvaddress: SGG ZV-->°o 197 Map: 4 -SF5 Lot: SSL{ BOH Reviewer: oS2T Type of Plan (new or upgrade): (iPGeAaF_ Number of Bedrooms in Assessor' s Records: 9 gpd) Garbage Disposal Allowed: tvd General Information: N.A. = North Andover Septic Regulations Other numbers refer to Title 5 OK Problem N/A Street number and map/lot - 220(4)(u) Maximum scale of 1 "=40' for plot plan - 220(4) Maximum scale of 1 "=20' for profile and component details - 220(4) Legal boundaries of the facility being served - 220(4)(a) Names of abutters from recent tax map - NA 3.02j Number of bedrooms, design calcs., - NA 3.02i Name & address of record owner & applicant - NA 3.02k Name & address of designer - NA 8.021 Holder and location of all easements - 220(4)(b) Date plan drawn & any revision date - NA 3.02m All dwellings and buildings, existing and proposed - 220(4)(c) Location of all existing or proposed impervious areas - 220(4)(d) All distances on site plan — NA 3.03a -c Elevation of proposed driveway - NA 3.02t Location and elevation of foundation drain - NA 3.02y Location and dimensions of the system incl. reserve ( new const.) - 220(4)(e) Limits of excavation of leach area on site plan - NA 8.02z Locus plan - 220(4)(t) North arrow - 220(4)(g) Existing and proposed contours - 220(4)(8) Locations and logs of deep holes - 220(4)(h) Locations and logs of percolation tests - 220(4)(1) Date(s) of soil testing - 220(4)(h) & (i) Existing grade elevation of each deep hole - 220(4)(h) Elevation of percolation tests — N.A. 8.02n Name of approving authority representative - 220(4)(h) & (i) Name of soil evaluator - 220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines, drains, and subsurface utilities - 220(4)(m) Observed and adjusted g.w. elevation in the vicinity of the system - 22_0(4)(n) Complete profile of the system to scale - 220(4)(0), NA 3 02c Cross section of leaching facility - NA 8.02w Location of benchmark(s) within 50-75 feet of facility - 220(4)(q) Note listing all variance requests with proper citations - 330(4)(p) (.v_-rrz - _ Local upgrade approval request form .vibmured - 4030, Ori;!nal R.S.T E. stamp, signature & date - 220(1) & (2) )V -i- - R =?ro,\ o eD sfc. supplies (w/in 400'), pub. wells (w/in 250'), pvt. wells (w/in 150@) - 220(4)( Location of watercourses, wetlands, wells, etc. w/in 150' of system - , A 8 02r Wetland disclaimer - NA 8.02s Land surveyor plan reference required (property line setbacks) - 220(3) Plan contains designer's certification statement Use approvals / standards checked for UA system - DEP docs., Perc rate >30 MPI - not allowed for new, LUA for upgrade - 245(1)&('3) Perc rate > 60 MPI - must use modified tight tank or /,A technology - _ 45(4) Proposed system qualifies as "shared" system - 002 (definitions) Flow is over 2,000 ()pd - No R.S. allowed - 220(1) Design flow was set in accordance with code - 203 Existing system location and note on proper abandonment - 600.3. 1 (f), 354 Leaching facility at least l' above Base Flood elevation - NA 9.05 All piping Sch 40 minimum - NA 10.01 Basement floor minimum I' above groundwater elevation - NA 5 04 On-site Soil and Groundwater Review OK Problem N/A 17 Proper deep observation hole logs on plan - 220(4)(h) Soil evaluation forms submitted within 60 days of Field work - 0 1 8(2) Proper percolation test log - 220(4)(i) Ample deep observation holes in primary disposal area (minimum 2) - 102(21) Ample deep observation holes in secondary disposal area (minimum 2) - t02(2) Ample perc testing (one in each disposal area, 3 in prim. > 2,000 gpd) 104( t) Hole Identification Numbers: V1� Qu -I ground elevation el. _ acceptable soil el. 233 Leach facility invert el. D round water el refusai el bosom of leach facility el. thickness of acceptable soil before & atter soil R&R separation to groundwater separation to refusal -- —" soil class t . perc rate10 MMCA loading rate �Sk septic tank below g w tables_ (yes or no) pump tank below L,.w table (yes or no) I fin till YES 25;(1) Setback Distances (Given in feet) 15.21 1 OK Problem N/A Is the lot in the Lake Cochiewick Watershed? NA 6.00 & 5.02 Septic Tank Leach Facility Property line 10 10 ✓ Cellar wall 10 20 Inground pool 10 20 / Slab foundation 10 10 Deck, on footings, etc. 5 10 Waterline 10 10 Private drinking well 75 100 Irrigation well 75 I00 Wetlands 75 100 _ Public well 400 400 _ Wetlands bordering surface 150 150 water Supply or trib. (in Watershed) ✓ Trib. To Surface Water supply 325 325 Reservoirs 400 400 Tributaries to reservoirs 200 200 Drains (wat. supply/trib.) so 100 ✓ Drains (intercept g.w.) 25 50 Foundation drains 10 20 Drains (Other) 5 10 V / Drywells 20 25 _ Downhill slope 15' to 3 l slope w/o barrier Buildina Sewer OK Problem N/A V Grease trap required for certain uses (check 230 for details) Pipe diameter listed (4" minimum) - 222(1) / _ Pipe schedule listed - 222(3) I Pipe cast iron or Sch 40 PVC — NA 11.02 Watertight joints specified - 222(3) & (4) Pipe laid on compact, fin base - 222(5) _ Pipe laid on continuous grade in straight line - 222(7)@ _ _ Cleanouts precede all changes in alignment and grade - 222(8) _ Cleanout provided every 100 feet - 222(8) Manhole at any 90 degree alignment change - 222(8) f Invert elevation at building: gr—,9l ) Invert elevation at septic tank: oC,)) Length of run: t6 / _ Slope: O.o'Z (minimum of 0.01 - 0.02 desired) - 222(6) _ 10' offset to private well or suction line - 222(2) Septic Tank OIC Problem N/A V Tank is accessible - 228(3) Tank can accommodate both primary & reserve — NA 9.04 _ 200% of flow (required & provided given. 1500 min.) - 220(4)(0 & 223)(1)(a) I 2-3" drop from inlet to outlet - 227(5) .Minimum of 4' liquid depth - 223(2) 3" air space above tees baffles (minimum) - 227(4) 9"air space above flow line (minimum) - 227(4) _ _ Tees are not to be replaced by baffles - 227(1) _ Tees extend 6" above flow line - 227(1) Inlet tee extends 10" below now line (minimum) - 227(6) Outlet tee extends 14" below flow line (more for deeper tanks) - 227(6) Gas baffle installed on outlet - 227(4) Access manhole cover above center of tank & each tee (except 2 compact) / 228(,) _ 3-20" manholes - 228(2) j 1 childproof, 24" riser/manhole to final grade if <I000gpd- 328(2) T _ _ Inlet and outlet tees on center line - 227(1) Soil compaction below tank specified (if soil is non-native) - 221(2) — 6" of <=3/4"stone beneath tank specified - 221(2) & 22 8(I) ✓ If> 1,000 gpd AND not a single fam. dwell. must be 2 tks or 2 comp. - 223(1)(bl If plan specifies disposal must be 2 tanks in series or 2 compare. tank - 223(I)(c) ✓ Buoyancy calcs. required if tank at or below water table - 2211 (8) Tank is watertight - 221 (1) 9" of cover over tank (minimum) - 228(1) H- 0 loading 1 (min.) - H-20 if traffic - 226(3) 7 _ Top of tank <=36" below grade - 222 1(7) All pumping to tank (if applies) in accordance with - 229 Tank is set to keep old system in service during install if possible Tight Tank (Check here if not present: .V ) Distribution Box (Check here if not present: OK Problem N/A -10 L J Inlet elevation: I Outlet elevation: 7 0.17' drop from inlet to outlet (minimum) - 232(3)(b) 6" sump (minimum) - 232(3)(e) All outlets at same elevation - 232(3)(b) Outlet pipes laid level for first 2 ft. - 232(3)(c) Pipe Sch 40 - NA 10.01 Number of outlets: �_ Number of laterals: j Size of oudets:L " ,/ Inlet baffle/tee min. 1" over outlet invert for all d -boxes - 232(3)(a), Soil compaction below distribution box specified (if soil is non-native) - 221(2) 6" of stone beneath distribution box specified - 22 1(2) Box is watertight - 221 (1) Top of box <=36" below grade - 221(7) Buoyancy calculations required if box is at or below water table - 221(8) Pump Chamber (Check here if not present✓ OK Problem N/A Volume specified: _ 220(4)(r) Pump on elevation- _ 220(4)(r) Pump off elevation: - 220(4)(r) Alarm on elevation: _ 220(4)(r) Number of cycles per day - 220(4)(r) (also 254(1)(d) if gravity Crom d -box) Minimum 2" delivery line to d -box if gravity - 254(1)( c) Pressure dosed Lf. if flow >= 2,000 gpd - 254(1)(a) & 254(2)(a) Cycles per day is consistent with chamber volume - 23 1 Volume calculations include flowback volume - 2') 1(2) 24 hour storage capacity above pump on elevation - 23 1(2) Number of pumps: 2 if system serves >2 dwelling units - 23 1(6) Capacity of pump(s) - gpm @ ' TDH - 220(4)(r) Pump can pass 1 1/4 "solids (minimum) - 23 1(7) Pump controls specified - 220(4)(r) Alarm equipment specified - 231(2) Alarm is in building and powered on separate circuit from pump - 2') 1(9) Pump sequence correct (off lead on -lag on-alan-n on) - 231(8) Pump perfonnance curves included - 220(4)(r) Manual operating switch - NA 12.01 Check valve, bleeder hole - NA 12.01 I childproof, 24" riser/manhole to final grade - 2'31(5), Soil compaction beneath pump chamber specified (if soil is non-native) - 1(,) 6" of <=3/4" stone beneath chmbr. specified - 221(2) & 228(1), Buoyancy calculations if chamber is at or below water table - 221(8)@ 9" of cover over chamber (minimum) - 228(1) H- 10 loading (min.) - H-20 if traffic - 226(')), Chamber is watertight - 221 (1) Top of chamber <=36" below grade - 22 1(7) Leaching Facilitv (general - complete for all designs) OK Problem N/A — 50% larger if garbage disposal - 240(4) Trenches to be used whenever possible - 240(6) No vehicle access or imperv. area above I.F. unless unavoidable - 240(7) t/ Vented if under impervious cover - 241 (1) V Vented through same pipes as distribution system - 241 (1)(a) Vent protected from precipitation/animal entry - 241 (l)(b) V Vent is placed beyond traffic or impervious area - 24 1 (1)(c) All lines connected to vent if bed or trenches - 24l(I)(d) --- 9" cover over peastone - 240(9) L/7 Reserve area provided (new construction) - 248(1) / Reserve 4' from primary leach area — NA 9.04 _ 4' (5' if perc rate <=2 MPI) separation to g.w. - 212(a) & (b) 4' (down to 2' with variance or I/A - upgrades only) of natural soil under I. C. ,L GW separation is adjusted to highest existing grade if facility cuts into a hillside Pipe slope minimum of 0.005 - 251(9) Require 5' removal and replacement if in fill - 255(5) ,/ Top of leach facility <= 36" below grade - 221(7) Final grade over l.f. minimum 0.02 11/11 -240(1 0) Surface & subsurface drainage away from I.f. - 240(1 l) & 245(5) 7_ 3/8"-5/8" orifices specified (gravity system) - 251(8) Minimum design flow 440 gpd without deed restriction — NA 13.01 3:1 slope where grading required - 25 5(2) Toe of fill slope stops 5' from property line or swale installed - 255(2) Impermeable barrier if < 3:1 slope or < 15 feet to —3: lslope 255(2) Impermeable barrier/retaining wall poured concrete — NA 9.02 Retaining wall stamped by P.E. - 255(2)(b) J Top of retaining wall >= top of peastone elevation - 355(3)(1) C'NU1065' 10' offset from edge of leach facility to edge of ret. wall - 255(2)(0) Perc test(s) done in most restrictive layer - 104(2) Perc test 4' below leaching elevation — NA 7.06 Design flow listed and required/provided leach area given - 220(4)(1) Leach pipes SCH40 PVC — NA 10.01 Leach pipes minimum 4" diameter except for dosed system — NA 14.04 Leach lines capped, vented, or connected together - 25 1(9) Pressure dosing guidance followed if pressure distribution - 254(3)(c ), Pressure dosing required over 2,000 gpd or with I/A remedial use - 23l(l) Leaehina Trenches (Check here if not present: J ) OK Problem N/A Number of trenches: Minimum of 2 trenches - NA 9.01(2) Depth of trenches (max eff. 2'): -247(l) Width of trenches (2' min., 4' max.): - 251 (1)(b) Length of trenches (100' max.): - 25 1 (1)(a) Trenches are vented (when > 50') - 251 (1 1) Trenches follow contour lines - 25 1(2) Trench spacing 3 times effective width or depth - 251 ( l )(d) In till or reserve between trenches, 10' min. - NA 14.01 & 14.03 Available leach area given (Min. 500 s.f.) - NA 9 01(2) Bottom = L x W x # = S. Sidewall = L x D x# x 2= S. F. Effective leach area given Loading factor: Effective area = total area s.f. x LTAR = g/day Effective area is >= design flow of facility being served 2"of 1/8"- 1/2" 2x washed peastone.- 247(2) Trench depth of 3/4" to 1 1/2" double washed stone - 247(1) Leaching Pits (Check here if not present: J ) OK Problem N/A of pits/pit systems: (dosing chamber if > 1, 231 (1)) Dimensions of each pit or system: L W D Depth of pits (max eff. 2'): 253(I)(a) Available leach area given Bottom = L x W x # of systems = s. t: Sidewall = L x D x # of systems = S.F. Total area = bottom + sidewall = S. f. Effective leach area given Loading factor: Effective area =total area s.f. x LTAR = /day Effective area is >= design flow of facility being served Minimum oft pits at least I3'X16' —NA 9.01(3) Distribution for galleries/chmbrs. in trench contig. - pipe every 20' - 253(6) Distribution for galleries/chmbrs. in bed config.-ea.pipe serves <= 40 s.f-253(6) Spacing - 2 times the effective width or depth (the greater) - 253(1)(c) 2"of 1/8"- l /2" 2x washed peastone.- 247(2) 3/4" to 1 1/2" double washed stone - 247(1) Each pit has at least one 20" access cover. 24" CI to grade over 2,000 gpd -253(3) Surrounding aggregate thickness between P (min.) and 4' (max.) - 253(1)(b) Vents, if necessary, extend under covers of pit(s) - 241 (e) Leach Fields (Check here if not present: ) OK Problem N/A J Number of fields: 1 (need dosing chamber if> I, 231 (1)) Length (100' max.): X36, - 252 (2)(b) Width: Z5' _ Total area: L x W 9')U S. f. Minimum 900 square feet - NA 9.01(1) Distribution lines connected with solid pipe — NA 15.01 Effective leach area given Loading factor: a.33 Effective area = total area qac s.fx LTAR 0,t a = y g/dav T Effective area is >= design flow of facility being served Minimum of two distribution lines - 252(2)(a) 6' line separation (max.) - 252(2)(d) 4' maximum separation from edge of field to line - 252(2)(e) 10' minimum separation between adjacent leach fields - 252(2)(t) Between 6" and 13" of 3/4 - 1 1/2" stone beneath field - 252(2)(g) & 24_7(_) 2"of 1/8"-1/2" 2x washed peastone.- 247(3) jSEPTIC PLAN SUBMITTALS LOCATION: 344 NEW PLANS: YES $125.00/Plan REVISED PLANS: YES $ 45.00/Plan DATE: "-ci Ag'� A& DESIGN ENGINEER: "C �Q6I A)J)CSG1-'U&&-P1XX DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary Town of North Andover, Massachusetts BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant NAME /� ^ADDRESS TELEPHONE Site Location Engineer Tn rour�nir Test/Inspection Date and Time 7 � _ Fee S.S. Permit No. X36 .W.C. N CHAIRMAN, BOARD OF HEALTH Test No. 7/7 '_C.C. Date 7-Z,~7X Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH d BOARD OF HEALTH .19 9k v f APPLICATION FOR SITE TESTING/INSPECTION Applican Site Location Engineer Test/Inspection Date and Time l �� S' �.'noAyi CHAIRMAN, BOARD OF HEALTH Z. Fee ��J , Test No. kS S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH o s m �tiRA�° EwaP " APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant e'\ -e r_A- t ,_}!'_ia .� NAME r ADDRESS TELEPHONE t Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. r) -->c- S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. HpRT1r a q s SSACHUSE BOARD OF HEALTH 30 SCHOOL STREET TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: v;-l2_c, LOCATION OF SOIL TESTS: 356 e- e- f Assessor's map & parcel number: /V( 6Ff> .30 1 cc/•C ( 1154 OWNER: s�ti��� 9_ TEL. NO ADDRESS: ?,,S CZe-o, Si, -f �8 ( -'AS3 8 ENGINEER: ems. TEL. NO.: 7 0G - i7 6 � lt�Y dt'_Q C. I C `V CERTIFIED SOIL EVALUATOR: rR,v\ &Z i 0610 Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 15 r I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Owner's Name: �Qfi lG .SAc.c.� GG��7S Property Address: N. AAI Mfg Date of Inspection: '1TJ� Name of Inspector: (� rA*A(j �.J�TrAIO I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) CERTIFICATION STATEMENT: Address of Owner (if different): Company Name: Mailing Address: Telephone Number: C Voluntary Assessment (Not Reported) Name I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes X Needs Furthe Evaluation By The Local Approving Authority Fails Inspector's Signature: 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 A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. 15ce 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. 1 of 10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 13,56 R&A ST-, ,l(,l ;4IDUUR I rA r Owner: M'i+ 0t 5 Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) J 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 ':Z)lS7;Z,,6077oAA/ obstruction is removed n �S R distribution box is leve44�r replaced /[ N 6_ 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: X Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy.is within,5Q feet of_a surface.water , Cesspool or privy is within 50 feet of a bordering vegetated wetlarid,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 of 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 P 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 com- pounds 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: SEPT` -7-4WV-. =:. Vi --7- P,PE 7_..rvVire,— .0"' 6et-o c/ �,Jo&K4n/C- X l-&-✓e-t, in/ TAn/-1- ; 0N1,Y ! of � U a4/ � 50,s sysT�+ r• � TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A pp CERTIFICATION (continued) Property Address: ICS S7—. A/ / A Owner: 1k f�IV -5 Date of Inspection: 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 7 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 SaC7 clogged SAS or cesspool. �G Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. —Iyv,�A Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool 6rrivy"is less than 100 feet'but greatei'han 50`feet from a private water supply " well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: #,10 You must indicate either "Yes" or " o" as to each of the following: The following criteria apply to large systems in addition to the criteria above: Yes No The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 feet of a surface drinking water supply. The system is within 200 feet of a tributary to a suface drinking water supply. The system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well). The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 3 of 10 Property Address: Owner: Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 =t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: 1 Pumping information was provided by t 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. r 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 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 intefior 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. The 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)] 4 of 10 Property Address: Owner: 4 Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION �, . FLOW.COND.ITIONS RESIDENTIAL: Design flow: //O g.p. /bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder: (yes or no) E.S Laundry connected to system: es or no) E.S 496 /906� 7�6 /935; 1011196 1960 j Seasonal use: (yes or no) /1/ C� Water meter readings, if available [last two (2) year usage (gpd)]: 7 1979 10 4- 9 H9 r 7 9% 2046' Sump Pump (yes or no): AIDA Last date of occupancy: hf12y 101f7 M64i 21MS ZoRS COMM ERCIAL/INDUSTRIAL: 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 date of occupancy: OTHER: (Describe) _ Last date of occupancy: GENERAL'INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: .1- 2 V/ZS P//UO2 TYPE OF SYSTEM: X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy NQ— Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of i A4 -C C WfflV eV73 AOP&/W- GA2 /G7 n/AZ_ 20 Sewage odors detected when arriving at the site: (yes Or no) /VU 5 of 10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 /C 44 sr, Al. �` A Owner: Ltl40k5 Date of Inspection: BUILDING SEWER: (Locate on site plan) ' T Depth below grade: Material of construction: cast iron 40 PVC other (explain) Distance from private water supply well or suction line: Diameter: Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:YE— (Locate on site plan) Depth below grade: ZZ" Material of construction: concrete metal Fiberglass Polyethylene other (explain) I If tank is metal, list age Is age confirmed by Certificat of Compliance? (yes/no) Dimensions: 4�E+" x 'O" (_1240 C i Sludge depth: NONE F Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: NONE Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: /ye^URAO 1N5,Z:Z=: Df '7,*iV !G. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) . S61anC - -72%0-6' 4a7" -01A5 8E4.04d6vZl4A/6-Z4L11 ✓EL G!� T"N!�' N _ %���'I��s/�ic��/�r�� / .T ate► �.. /���.�T4��� t _ _. �r•�r /--/U vL LEVEL- eVEN To ZT?lTI IWVell�7 -�iVk—' fh'efl lM 677WU'vr2i!UV -50LI J1.-, W17N �c/n GREASE TRAP: Depth below grade: _ Material of construction: (Locate on site plan) 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, structural integrity, evidence of leakage, etc.) .. i TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _'�5 S7 , N. IN W6W q14 Owner: f1'7-5 Date of Inspection: 15-- TIGHT OR HOLDING TANK: NU (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: Gt1 /7 f/ Z d U17?S (Locate on site plan) Depth of liquid level above outlet invert: O/1)f•y . 8r17"PE �T�Ar 4i1/T Comments- (note if level and distrihution is ani mI avidanca of cnlirk rami nvcr ovirfonro of Innbnno in+n — „­+ „4 k^w „+,. N S6't7—e24 ,4k PUMP CHAMBER: (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.) 7 of 10 Property Address: Owner: Date of Inspection: OF Z PiT.sa PS SOIL ABSORPTION SYSTEM (SAS): CSP AI& (Locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) .3s6 k6A sr., Al.,-' IVA Type: 70'1Z_> �D Leaching pits, number: 2 5 7 dAU.VZd 'Zs 94$ &C> I Leaching chambers, number: Leaching galleries, number: Leaching trenches, number, length: Leaching fields, number, dimensions: NO- Overflow cesspool, number: -7-75 Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: Iry (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: NO (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.) on TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3% Ae�l �<37--,, OtI � �# Owner: 1A JAIS—;e-5 i Date of Inspection: 9 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) . . . . . . . . . . . . . . . . . . . . . . . . . ..... CIA Ipme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... ....�.G. .�. . . . . . . . ,..6. FANT . . . . .q .�. . . . . . . . . . . . . . . . . . . . yw . /Zoo C -mss srr�,, . . . .�. ......... �.. 7o LEACH PIT "A" {- � . . . . . . . . � C �: � p � . . � � • 2 owner Jam. 4sT 6077aA 2S "•�a7J ,Bok 6-�� PST 9 of 10 Property Address: Owner: Date of Inspection: TIGER ENVIRONMENTAL -ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) DEPTH TO GROUNDWATER: i Depth to groundwater: 4+ feet �8C-k)Al a)/S_/X4607_/4K/ AX Please indicate all.the methods used to determine High Groundwater Elevation: r Obtained from Design Plans on record X Observation of Site (Abutting property, observation hole, basement sump, etc.) 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) /F'Ei/�AG d IAlb ICAi-i4&/ of 69OZOWt7aQ �JRr�n/T T Sr9 s 16v1A4+A17-1,y Loa/&Z /Af 61ZOIDE A107- 6QO 1 /tet hZ67Z 9 The intent of 310 CMR 15.302 is to provide reasonable guidelines for the inspection of existing systems in as non -intrusive a manner as is possible to avoid damage to the system and any unnecessary disturbance of the surrounding soil area which is related to the treatment process. The inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the new owner. The inspection criteria are intended to allow for timely inspection to avoid undue delay in the transfer of property. I understand that this report does not constitute a warranty or guarantee of future operation. Client or Representative Date T 17, r ;,ql E tj FR (T L N'T Cc: cs-s 1 Ki 0 Su t7 _) (j 3 3 W3 Fj E C TAIAK c.ApAc, 308 G P -D F AC H cr ij T 17, r ;,ql E tj FR L 0 T I I OA A OT IIIAA6 50,SC)iS S F V) t; 7r 4j 4.--- INV PIPE: col FO(JSE- INV PIPE OJT OP -TAWKt: 1NV PIPE OU -r OP 'iP.q(, INV. @ PrT 'A - y 13 - INV @ PIT'Lk - Vl,iAWK C- (-7E1_INA5 t ASSOCIATESI ARCHITECTS 1 451 AKIDOVER ST INO ANDOVEq)MA.: -7 C, rd1kP } TOWN. OF NORTH ANDOVER i SYSTEM PUMPING RECORD x;j si-ir�!4��i°"�p�`St��Y DAT NFAt , z I Ltf Js tlw+tf i{t ,t °j„° { SYSTEM OWNER &ADDRESS SYSTEM LOCATION y. w �t> 4t";�Y (example: left front of house) tl �'S f°fir si,t r ,g"P it ti ' if i �; ��xakr�''W�ajr Al klga t�l L+P{•. � } a 7 / �NJ�µ51 ix$ .J{' �.;^ 11r,.y, ra;?i'ri11ie!"r t'N y •NJ; Its' ! k � t. �i � k .� !, S ,. ° .,! '4 ', . ..��t .. ".- .. DATE OF PUMPING: 'k ` 6 QUANTITY PUMPED GALLONS p l j k R"' !CESSPOOL:` NO YES SEPTIC TANK: NO _ YES,�' ! .., ..� „ Vic` ,fi NATURE OF SERVICE: ROUTINE EMERGENCY �` k N."M 31 �, ,11� 3-G40 .;CONDITION � FULL TO COVER ,.R!�. S i � � HEAVY GREASE � ' •.�._r..,. _ i My t fp BAFFLES IN PLACE _ $ } ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED —' r '�""�"'r"wwn .... �� t SOLIDS CARRYOVER . OTHER (EXPLAIN) ! r �'i}r��ri� u +ls'V P.d :, 4. q ty,t ,.i,s .,. I � tl„• a is tS PUMPED BY: W ' a�/tYil��ir �{w�q!, ijiz�,i.t _�� ���p i�� ,`.� c..•' �r I 4' 7ONIMENTS: 4 A IT.' !A - r- t TANTS TRANSFk'RREI� TO 1 t�2(2L�_ RAI'r � 0. � t k u • s L �� � �[x i i +:; i� l � ij +l.illt7'� 7{ j”' 5 ! •fit%�x �� "E+ '� }.. + �• i k if'4'U � �lY�A�b�'�I•,/eK�. ��r P�f f�tl&�. '�''? °k 1. t COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICIAL INSPECTION FORM N T FOR VOL SUBSURFACE SEWAGE DISPOSAL VOLUNTARY FORM SYSTEMPART A CERTIFICATION Property Address: 356 Rea• St. Owner's Name: JoYn C Owner's Address: - Date of Inspection: - Name of Inspector: (please print) Jctm Saucy Company Name: Qa2es Segnae S�� Mailing Address: iazwmm St r.� 01876 i Telephone Number: (m8)A�1-5839 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the informat' below is true, accurate and complete as of the time of the ins ion reported training and experience in the proper function and maintenance of on site sevpva e� disposal erformed based on my approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000). The system systems. I am a DEP X. Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: G — �o The system inspector shall su t a copy of this ins DEP) within 30 days of completing this '0n irt to the Approving Authority (Board of Health or gpd or greater, the ins g system inspection. If the system is a shared system or has a design flow of 10,000 inspector and the s tem 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 time. This inspection does not address hpw the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 356 Rea St Owner: Jdn Cern r Date of Inspection: 6-5-0 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: 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 ormore 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 11 OFFICIAL. INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 356 lba St _N Arjpr. BA 01845 Owner: T.a,,, n;, Date of Inspection: &&m 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 Ts 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 5.0 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 356 Pea St Owner: i Cera — Date of YnspecUon: 6-5..02 D. System Failure Criteria applkable to an systems: You &W indicate "yes" or "no" to each of the following for 11 inspections: Yes No .2L Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6" below invert or available volume is less than % day now -- x Required pumping more than 4 times in the last Yea HgLdue to clogged or obstructed pipe(s). Number X of times pumped ____. Any portion of the SAS, cesspool or privy is below -high ground water elevation. --. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface X water supply. x My portion of a cesspool or privy is within a Zona 1 of a public well. -- - X 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 supply well with no acceptable water quality analysis. (Thb private water performed at a DEP certified laboratory, for conform bacmria an@a voatile o well water analysis, Indicates that the well is Ira from pollution from that facility and the presence of ammonia compounds nitrogen and nitrate nitrogen is equal to or less tban S ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) —M (Ym No) The system I 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 corMt tha failuro, E. Large Systems: 10 To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to IS,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) Y03 no ,Z• the system is within 400 feet of a surface drinking water supply X , the system is within 200 feet of a tributary to a surface drinking water supply �X 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 "Yes" in Section D above the large system has failed. The owner is considered a significant threat, d answered signincant threat under Section E or failed under Section D shall operator of any large system considered a 15.304. The system owner should contact the appropriate regional office ograde f the Diem in accordance with 310 CMR . pargment. Page S of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3% Pea St N , Owner: _Jctn Cbz Date of Inspection. =5_02 Check if the f011Owinit have been done. You must indicate es" or "no" as to each of the following: Yes No X — Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system con Potents Pimped out in the previous two weeks ? X Has the system received normal tlows in the previous two week period ? x Have large volumes of water, been introduced to the system recently or as art of this inspection pection ? .X— — Were as built plans of the system obtained and examined? (If they were not available note as N/A) x , Was the facility or dwelling inspected for signs of sewage back up ? x Was the site inspected for signs of break out ? ..X . _ _ Were all system components, excluding the SAS, located on site ? Z, Were the septic tank manholes uncovered, opened, and the interior of the tank ins of the baffles or tees, material of construction, dimensions de Petted far the condition pelt of liquid, depth of sludge and depth of scum ? x _ Was the facilIty owner (and occupants if different from provided with information on the proper maintenance of subsurface sewage disposal systems ? own The An and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no x --- Ming information. For example, a plan at the Board of Health. Detenained in the field (if any of the failure criteria related to pan C is at issue approximation of distance is unacceptable) (3 10 CMR 15.302(3)(b)j 5 Page 6 of l I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:. 356 Iba St Owner: John Chu zulll 01845 Date of Inspectlon: RESIDENTIAL FLOW CONDITIONS Number of bedrooms (design): 4 Number of bedrooms (actual): 4 440 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: 3 Does residence have a garbage grindoi (yes or no): � Is laundry on a separate sewage system (yes or no): W_ (if ye, separate inspection required) Laundry system Inspected (yes or no): Seasonal use: (yes or no): ,— Water meter readings, if available (last 2 years usage (gpd)): sae attached Sump pump (yes or no): Last date of occupancy: -- COMMERCIAIJINDUSTR AL N/A Type of establishment: Design flow (based on 310 CMR 15.203): mid Basis of design flow (scats/persons/sgft,etc.): Grease trap present (yes, or no): _ _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title S system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _! �rifo Was system pumped as part of the inspection (yes or no): yes If yes, volume pumped 1.,500 ,gallons _ How was quantity pumped determined? 9� acic cn ta Reason for pumping: • cn t D inba-icr• cf tal* 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/Altetnative technology. Attach a copy of the current operation an od 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 installeda (if kno n and source of information; Jure 17 1998 as shaam�Z dPia I Were sewage odors detected when arriving at the site (yes or no). M 6 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (wrid wed) Pmp" Addr4; 356 Rea St N Arrb.Nh01M Owner: Jdn Date of Inspection: 6 - BUILDING SEWER (locate on site plan) x Depth below Stade: 0" Materials of construction:—`,cess iron _40 PVC _od � (explain): Distance from private water supply well or auction line: A Comments (on condition of jojoins, venting, evidence of leakage, etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 4 Material of construction:x couct+ete metal � fiberglau lolycthykne _•other(explain) , If tank is metal list age; _ Is age oonf rmad by a Cemfime of Co lin es or no certificate) mp (Y 110): (attach a copy of Dimensions: Eft IV 12ft Sludge depth: 210— Distance from top of sludge to bottom of outlet too or baffle: 36" Scum thickness: 21 ' Distamce from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet too or-09.7— How How ware dimensions determined: _ Gi„ }�,r,� Comments (on pumping tecommeAdatsoms, inlet and outlet tee or baffle condition, structural into AS related to outlet invert, evidence of leakage, etc,); integrity, liquid levels GREASE TRAjg1A_(locate on site plan) Depth below grade: Material of construction: ,_,_,concrete _metal ,rfibagl&ss ,_,polyethylene other (explain): Dimensions: Scum thickness: Distance from top ofp of scum cum toto top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or belles: Date of last pumping; Comments (on Pumping re'commendauons, inlet and outlet tee or baffle condition, structural into as related to outlet invert, evidence of leakage,, a%.):grity, liquid levels 7 Pages of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 lea St Owner: a n brm Date of Inspection: TIGHT or HOLDING TANKNL (tank must be pumped at time of inspection)(locate on site pian) Depth below grade: Material of construction: _concrete _metal ,fiberglass _polyatbylena othar(explaia): Dimensions: Capacity. aatlons Design Flow: aaLotts/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 (if present must be ope CMOcate on site plan) Depth of liquid level above outlet invent: 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.): PUMP CHAMBER: N_ (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 ofpumps and appurtenances, etc,): Page 9 of 1 I . OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 Pea St N ArrYr r.Nh 01845 ._ Owner: -Tcbn Cd1Q7 Date of Inspection; E=(ice" 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, len x leachingfief ds, number, dimensions: overflow cesspool, number: innovadve/ahernative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS:NJA (cesspool must be pumped as pari of inspectionxlocate 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 (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: UZA_ (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.): 9 Page,10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 Rea St Owner: Jchn Date of Inspection: &5-02 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. rr, t r 10 BENCHWRK: 70P \---�ORNFR OF ELEVFRONT.�� 100.00 Page 4 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 Pea St N Armor. Owner. Date of Inspection: 6-5-02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 21 j51O 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: 6-17_98 Observed site (abutting property/observation hole within ISO 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 es%blishss4 the blub vrnunwa�et el � � WtE' est&l-�ed fmn-deign Ow c &A"- 98 11 r m a. 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'r �'::'i= TUU 44,T(T N?A O(TNTV TTT-,Tr)AT r r r� nc /1 n r n -ci r rn • x I TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE ) I'7_ 03 SYSTEM OWNER & ADDRESS W i I1 1,am sor) .3�b Rea s. N-ono6o,ee,,ma. _ SYSTEM LOCATION DATE OF PUMPING -<5):3 _QUANTITy PUMPED_ CESSPOOL NO SEPTIC TANK NO NATURE OF SERVICE: ROUTINE �E RGENCY OBSERVATIONS: GOOD CONDITION-FUd TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY s COMMENTS: CONTENTS TRANSFERRED TO —? YES 'L___.- • /D Vii/ `SYN• 1.•1•. :: ••f.q%'. /i V �:••.. �1�/••..• ,• ••I t 15. 1 1• • ' 009 •_TOWNOF T. • w Oe;o o! 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Pvm,pinq' . �• •rYDa 91 ryslom;.,' C,1 Caps oolO ••r. .,; .... 1•r .. � 9�aDl!C Tangy %Other (dascrir;a� • ... •.:...`.r.,. �6���',C�ondlyori'Q(,9yt, m ''�:• , . -' �•.1•�I',/1;,11 :,Ja ,,, ,� .. , p%/}') ., '��•�i:'.^���J'1,�r1��t`� U�.I)�,r.i���1't'�I�J'���'''��1,�. l /• 44 �OC�1Y ,;,.t,1,•. 1, t -- on.or�toor�lanU;ware dI p �,.,.�,�,•r.maw,govldoh,.yre(oylepD�OYeJaJlblorm�.n�maln9�aci '” l 15n; ra-. 11 ye 3, X65 1(c sanao? '7 res _ Yi�lu�'Jcenll���! •-. � ai.1+h ��fh ae +�� N �;`' tfA r:.�wy}vt,l+y>£i,�,�t� �C� +�; � y ,�, +, ,,+ 1-`.1��(t htj•V 47Gf�k��.r1>l�v �. rK +�, SHL,, t i�,l� Commonwealth of Massach City%Town'of NORTH ANDC . SystemPumping; Record Form 4' DEP has provided this form for use by lop be submitted to the local Board of Health A. Facility Information Important: _ When filling out 1, forms on the computer, use only the tab key to move your cursor •. do not use the return key, 2, System Owner VQ Name C JL _ 7 2010 m Pumping Record mu,, Ca . Address (if different from location) City/Town State Zip Code Telephone Number 6, Pumping Record 1. Date of Pumping para 2. Quantity Pumped: Gallons 3. Type of system:.. ❑ Cesspool(s) L/Septic Tank EDTight Tank {] Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If ye§,'vvas it cleaned? ❑ Yes ❑ No S. Condition of System: a)oc 6.. stem Pum By: 9 me Vehicle License Number Company me - 7.. occatlop where contents were disposed:10 A , atur'e of Hauler . http://www.mass.go /dep/water/approvals/t5forms:htm#(nspect t5form4.doa o6= SJ System Pumping Record Page 1 of 1 Commonwealth of Massachusetts City/Town of No.Andover System Pumping Record ;M Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Ma State State Telephone Number /0 — v/ 2. QuantityPumped: Date p ❑ Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: ® or/ 6. em Pum By Marne Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plano. Mill Bradfor Signature of Hauler Signature of Receiving Facility t5form4.doc• 03/06 IVSD lav 1UNil TOWN OF NORTH ANDOVER 1845NLTH DEPARTMENT Zip Code Zip Code Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 Date/'/ Date System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System ocation: forms on the computer, use only the tab key Address to move your No.Andover cursor - do not City/Town use the return key. 2. System Owner: 4:1 a _ _It kfA +1( /eh0/ Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Ma State State Telephone Number /0 — v/ 2. QuantityPumped: Date p ❑ Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: ® or/ 6. em Pum By Marne Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plano. Mill Bradfor Signature of Hauler Signature of Receiving Facility t5form4.doc• 03/06 IVSD lav 1UNil TOWN OF NORTH ANDOVER 1845NLTH DEPARTMENT Zip Code Zip Code Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 Date/'/ Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED W City/Town of North Andover I LE5 2013 a System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMNT M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r� 1. System Location: 15(c 1`-C Address North Andover City/Town 2. System Owner: r Name Address (if different from location) City/Town Ma State State Telephone Number 01845 Zip Code Zip Code B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes i No 5. Condition of System: 6. System Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: Signature of Hauler 7ignature of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 835 Date / Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of' Massachusetts City/Town of No Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return System Location: Address key. City/Town State Zip Code 2. System Owner: 2 t Name Address (if different from location) CitylTown State Telephone Number Zip Code B. Pumping Record 1. Date of Pumping Date~� Quantity Pumped: Gauons��� 3. Component: ❑ Cesspool(s)Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Observed condition of component purr 0 7 System Pulp ' C�_ Name Stewarts Septic 58 So Kimball St Bradford Ma Company Location where contents were disposed: 20 so mjU-srbr-adford ma Signature of Signature of Receiving Facility (or attach facility receipt) If yes, was it cleaned? ❑ Yes ❑ No Vehicle -7-- /9” License Number Date Date t5form4.doc• 11/12 System Pumping Record • Page 1 of 1