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HomeMy WebLinkAboutMiscellaneous - 357 DALE STREET 4/30/2018 (2)No D1 T a CU Ul U) I L Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH o�sEo 0 19 9L L APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ADDRESS TELEPHONE Site Location IXt_ . Engineer V'o NAME ADDRESS TELEPHONE Test/Inspection Date and Time CNG' 7, Fee lM CHAIRMAN, BOARD OF HEALTH Test No. % 13 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 19 s - � APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. ' S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. r i W l2 y YLn o ��.... res f9xi ©v-' ho•` (� � Nor��i Andvv�r f: a \ �! � D 40 _ �'Vatuh�rry d �a/c.uinc� K. Nac�vb�rrry PLAN OF LAND IN -AN DOVE MA5150-- AS SUPVEYE D FOR - n a w m c � Z m N J m O m nJ d O n, r— m m N N J "- J 00 (a « m x o� �x W � y f'wm QI-v ••� <w UJ NQ w w�- n::13J JC m UJ W� U—<>.. cr (r< <> Lo5 ¢ 1 � �,� z�J.i� • � Omi U aHpa W d 1- u -m r> '. �L IL .. m J m ^ OOca .• a c 0 �2� •� 1 LL orn 1—WAQ � ° C), m WOIL'm ESAIL•• i N o 1-7 I •a L c c CL Q} ` oc xAQ< vm 41--ISAc my ]L2'WZL ma) b W A o 7 Z Q ri 2 rtZ F riy� n� o m Z 1. N U- <> w aX Z~ a 3� LL U 3 O jw a O¢ 1 ° cn 1—O N U W LL J O O N� C) z'. = w uN _O _ H W LL R U O w LL z w <z O w U.O O U w Cl LLIo W x a¢ in OLL F x cc fY aw d LL' w E 0 Q •F-� =W 0 VW C) JfL�W m � A w R"2WZ 0 a A Q a 3Q!AS a 1- 0 V31�fk w A�f10 F W Wm Z, OEI;E lZY00S S✓NLIOJ SS7Njsno VJVO NOIDNIl1.IV 14) _n rD R) C:) C3 C3 O C3 a C3 O O m m n� i 0 �Ul Y ' M a ' O U H a 0 z O 0 z J Q a a rn f - x O a O U 7 MAP AND PARCEL i ADDRESS OWNER SIZE OF LOT IN SQUARE FEET # BEDROOMS SEPTIC SYSTEM LOCATION O Vio (For example, FRONT YARD SOUTHEAST FINAL GRADING DATE Mu - AS BUILT PLAN IN FILE? v ! 0 INSTALLER DWC PERMIT DATE CERTIFICATE OF COMPLIANCE DATE ENGINEER SA -ti 0 •-4", 7 William F. Weld Governor Argeo Paul Cellucel LL Govemor Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION r c Trudy Coxe S—vtary David B. Struhs COmm1W{ xw 77 -19 Property Address: 3,5_7 Da I c AJ Date of Ins Address of Owner. Inspection: 1II 7-1)g7 (If different) Name of Inspector: Benjamin C. Osgood Jr. Company Name, Address and Telephone Number. New England Engineering Services, Inc. 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes _Needs Further Evaluation By the Local Approving Authority _, Fails Inspector's Signature: O Date: , r1Z_1q 7 The System Inspector shall 2-t a copy of this ins iozrt to t inspection. If the Po he Approving Authority within thirty (30) days of completing this 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: Aj 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. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, 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 Fonforming septic tank as approved y the Board of Health. (revised 11/03/95) One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292.5800 A %i Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addr—m 337 Oglc 5.4- W, Owner: W c lc k Date of Inspection: 4' Z9ia'7 Bj SYSTEM CONDITIONALLY PASSES (continued) _, Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction in removed distribution boat is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. I) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. &5- /=gyp m 1-„e n c 1, 6 -( 1i b V f ---a r �y _ The system has a septic tank and soil absorption system and is within a Zone.I of a pubrL water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than 5 ppm. S) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 j 7 OA(c- sf"te+, N, 44 pv-t4, Owner: L dL vvcl�l�. Date of Inspection: D] SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 35 7 D c l c S -h N- Fr A o -+ tt Owner. w c lc �► Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /vi 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 interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. l _ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. /The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address ,3j ? 0Q lc s7).Y cY ti 19j, Owner. F� ."t, Date of Inspection: 4 IIZ9)9'7 FLOW CONDITIONS RESIDENTLAI_ Design llow:_____g&uons Number of bedrooms:Y Number of current residents: / Garbage grinder (yes or no) -- Laundry connected to system (yes or no): Seasonal use (yes or no):_ / Water meter readings, if available:� _ % �7 ./h its z Sy Inst date of occupancy: Cu-i'en`i'*- COMM ERCLkLANDUSTRIAL 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 d source of information: Puw.o < ;^ lgcfP System ptimped as part of inspection: (yes or no)_/ If yrs, volume pumped: ¢allons Reason for pumping: TYPE OF SYSTEM _ ' Septic tanWilistribution box/soil absorption system Single cesspool Overilow cesspool Privy Sbared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information:�j Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: 3Jr7 Dae S M- hn&, C4 Owner. k tA! e Ic � Date of Inspe6tion: 41 Zak q SEPTIC TANK:_ (locate on site plan) Depth below grade: �i r �/ _ Material of construction: V concrete _metal _FRP —other(explain) Dimensions S' X.S� x 3b" Sludge dept i, Distance from top of sludge to bottom of outlet tee or baffle: Z 7 , Scum thickness: -41 " Distance from top of scum to top of outlet tee or baffle: ►1 �� ee-/ e do w Distance from bottom of scum to bottom of outlet tee or baffle: / L 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.) 7-1411 K -S Hc7tvLn H A'Je of /V C- I I NS T?i`t L e O GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP --other(explain) Dimensions• Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baMe: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3_57 O A l c &f' /i/' - 4,,10Q %, t t Owner. F& w' lc k Date of Inspection: '11 211q -7 TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX -_Q" (19cate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids evidence of leakage into or out of box, etc. G PUMP CHAMBER_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address 35 7 0 acic Sf: A). A ^ X o v zr- Owner-- F& w e tc �^ Date of Impaction: N I zq 19 7 SOIL ABSORPTION SYSTEM (SAS)-_ (locate on site plan, if poasR)le; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: leaching pits, number:_ leaching chambers, number._ leaching galleries, number. leaching trenches, number,length: / B5'� Lo.�, f�-jc k leaching fields, number, dimensions: overflow cesspool, number- Comments: umber Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of 11% r^ .1 n CESSPOOLS: _ (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: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3,51 D a �c 5 �' N - �..� 0 Owner. F& Date of Inspection: H t Z 91 q7 SERTCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' C�1 1 'Tv j r -i �✓7'R�y DEPTH TO GROUNDWATER Depth to groundwater -._ (_feet L Ll method of determination/f or approximation: e Ie,- n � fl 6^ CJ� C Q #X& Ui I•'�r CGL 4nC J G.S fill �Y1 (revised 11/03/95) 9 t__ William F. Weld Governor Arg" Paul Ceilucci LL Governor Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION j::f le. it 77 -1q Trudy Coxe Ssaetery David B. Struhs Commtr toner P—Perl'y Addreew 35-7 DateAJ, Address of Owner. Date of Inspection: L)I Z01'7 (If different) Name of Inspector. Benjamin C. Osgood Jr. Company Name, Address and Telephone Number. New England Engineering Services, Inc. 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 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 _441'*' eeds Further Evaluation By the Loral Approving Authority Fails Inspector's signature:A (2 Q Date: �`i f C� 7 The System Inspector shall suHfnit a copy of this ins 10 port to t inspection. I the system ll a shared p° he Approving Authority within system or has a design flow of 10,000 or orthirty an (the days of completing this report to the appropriate gPd greater, the inspector and the system owner shall submit the p° PP priate 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: AJ 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. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked structurally unsound shows substantial infiltration or exfrltration, -or tank failure is imminent. The system will Pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500 A �i Printed on Recycled Paper ��.� F _� . '��, , d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address 3,57 Dalc S+- /1/, 4}jo,,-V1 Owner. r -A- (,,v etc k Date of Inspection: 4' Z9la'7 Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water su 1 . 1 � PP y � !ilio v►� ret c � �-o fire 6 v i� r The system has a septic tank and soil absorption system and is within a Zone I of a pubg water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds 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. 3) OTHER (revised 11/03/95) 9 (56/£0/61 PaSIAaJ) uot;v=gjut saquW soj }uamuWa(l aq; jo aoU;o Teuo!Sw Tmol eq; }lnsuoo aseald •00.9 pue 00.4 HIqO 1,1E jo s}uamaimba: utas8osd ;uau v-%4 sa;ampunos8 aq; g}tm aoustldmao Hnj o;ut S;tTtoaj Pus uta}sSs aq; Sttuq rlegs tua;sSs Bons Sup jo so;asado so saumo aqy (Ilam STddns sa;em oggnd a jo II auoZ paddatu a to (t/&MI) easy uot}oa;atd PVDXMOta uttte}uI) Vasa ant;ffiaae ua8o6Z;tu s us Pa;eool st usa;sSs aq; — Slddns sa;em BuPlutsp aoe3sns is a3 Sss;ngtz; a jo 3aaj OOZ u?t+tm st ma;sSs alp Slddns sa}em 8ua(uup aasjsns a jo ;aaj 00V utq;tm sc MaVL aq; — :Vn- suot;tpuoo 2m-olloj aq; jo asom so auo asnsoaq;uamuostnua aq; pus S;ajes pus q;Isaq otlgnd o; ;eatq; ;usogtu8ts t3 ss sua;sSs aq; Pus (usa}s6S a") sa;eas8 so PdS 000'01 jo mol; u2tsap a q;tem S;tltoej a sansae tua;aSs aqy :anoga etsa}uo aq; o; uot;tppe ut smaw" a8sel o; Sldda assa;tso 8utm0110j alu :S'IIv3 NP3.LSAS aouvI [a •ua8os;tu a;as;tu pus ua8o4tu stuounus 'spunodmoo omu&ars;elon 'euapeq tusojtloo soj 9c861aua sa;Bm Ilam jo Sdoo goe}}a 'alga}daooe aq o; pazSlsaa uaaq seq cram aq; jI •stedretta S;tlenb sa}em aige}daaos ou q;tm Ilam Slddns sa;am a}enud s mos; pet; 09 ussi} sa}eaa ;nq }aaj OOI usg; seal ec Apd so loodssao a jo uoypod Suy — `Ilam Slddns sa}em a;enud s jo ;aaj 04 usq;tm st Saud so roodesao s;o uotod ¢ny — 'Ila- otlgnd s jo I auoZ a utq;tm sl Saud so loodesao a jo uot}tod SstV — •Slddns za}am aosjms a o; Sse}nqu} so Slddns sa;em aoejsns a jo;aej OOI utq;tm sl Spud so loodssao is jo aot}sod Stty — not IRAOTO sa;empunos8 g2N eq; molaq ss Snud so loodesao 'uta}sSS not}dsosgV ItoS aq; jo uoptod SuV — padumd saun} jo saqumN •(s)adtd pap -}-go so pa88olo o; anP TO—N seas }sal aq; ut sawn; q ueq; asolm Sutdumd pasmbag — .'IOU SHP Z/i ueq; —1 9! atunlon aigeltees so }tams molaq „g ueq; seal st loodseao ttt q}dap ptnbrl — •Ioodssao so SVS Pa$8o13 so Papaorsano ua o; anp jJansn ;al;no aeoge xoq uot}nqu}stp aq} ut lanai pmbtl of}a;S — •loodssao JO SVS Panop so papsolsano uv o} anp ssa3sm aosjsns so punos8 aq; jo aasjsns aq; o; ;uanlga jo Butpuod so a8sagost(I — •loodssao so SVS paMp to papvgzano us o; anp ;uauodmoo ma;sSs so S;gsoaj o;ut a8amas jo do -long — aR3 130si00 o; Ssessaoau eq 1p- ;eqm ouT—egep o; pa}as;uoo aq Plugs gjMH jo Pig aU *,molaq pat;t;uapt et uot;satnuaWp alp Soi stseq mM 'SOE'9i WqD OIE us p=gap se atsa;uo asnitaj Susmolloj asp jo asosu so auo sa;alotn teals" aq;;ag; pauttus" an8g I :91IVLI i1(Hd.SAB [Q L��bx�h Ni 2Y) CYI :aopoodsul jo a;a(l.�o� ' (V �.a a► 5 �� b� L PPv 4j�dojd (panm;uoo) NOLLVOI3LLIM:) v ,Luvd i uoa AIOLLO'3dsm i4'3,LSA9'IVSOdSIQ 3JVA;IHS 3OV3IMSEMS I Property Address: Owner. Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 35'7 �al� E� we�c� Li►vli a? Check if the following have been done: SA -7 A) • Pr J o --t& Pumping information was requested of the owner, occupant, and Board of Health. �Noae 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. /VA As built plans have been obtained and examined. Note if they are not available with N/A. 1� 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 interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. f The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. /The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) 4 Property Address: Owner. Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 337 Oa/c S-�.reY e-5/ , (C A 41V)Iq-7 A/ A46 , FLOW CONDITIONS RESIDENTIAL.• Design flow:_ gallons Number of bedrooms:Y Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no): Seasonal use (yes or no):— / Water meter readings, if available: "7 or. ,zs Last date of occupancy:—Cy—,—en-1" COMMERCIAL/INDUSTRIA :- Type of establishment: Design flow:__ gallon/day . Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yea or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS end source of information: System pumped as part of inspection: (yes or no) Al If yes, volume pumped: ¢allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: .21�—' -3 L) d C010-5 61cS/ Sewage odors detected when arriving at the site: (yea or no)A% (revised 11/03/95) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 357 f).,)# a)2 S N- �✓�d/Jv t2 Owner. k aC W e Ic h Date of Inspection: 41 Zr.(1a'1 SEPTIC TANK_ (locate on site plan) Depth below grade: is c r Material of construction: ✓concrete _metal _FRP —other(explain) Dimensions: S' X-1) x 38" Sludge depth /' .` Distance from top of sludge to bottom of outlet tee or baffle: az Scum third: •L) " Distance from top of scum to top of outlet tee or bathe: t��CC, e.(bow Distance from bottom of scum to bottom of outlet tee or baffle: _/ (. `• Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) %i4•t11S _S Hy Q ih H Ay e pf Al 0 T I ir'dF_ 1 NS 77�t L-0 GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bathe: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 r ,I .r , • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3,$ 7 0 g 1, SiT Al - A ncuo � rit Owner. W e t c � Date of Inspection: '11 2 1I a 7 TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP —other(explain) Dimensions: Capacity: ¢allons Design flow: Rallons/day Alarm level: / Comments: (condition of inlet tee, condition of alarm and float switches, etc.) el DISTRIBUTION BOX. -V (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids evidence of leakage into or out of bo:, PUMP CHAMBER_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) a c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 ? 0 celjc e, N, A.. cit o v v - Owner. wc.1c Date of Inspection: H f Zq 19 7 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching Pits, number:_ leaching chambers, number:_ leaching galleries, number- leaching umberleaching trenches, number,length: 8 y L o.�, tF t• l c 1k leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of 0 CESSPOOLS: _ (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: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address;- Owner. ddress Owner. Date of Inspection: 9 47 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' - — Au131- Bz>x 1 'iv j r -i �J7'ary DEPTH TO GROUNDWATER e Depth to groundwater- Aet 1 r- L �1 method of ruination r approximation: 2 lTl cin . (revised 11/03/95) 9 c on 3 Z m Q E LL Cv) Q L O N L N -O +' w U � O L N b�A � r--+ L U U Y � rd Z v) J Q O >- LnC �+_- w F- W L _ fd J Q= O U > = U- U O Q O O 0 LL C c) LLJ w c Q LA m O_ st m ~ N O Q o CL c v Z c W Q c A U o ° a as u r� T L rz d C N U L 04 v, .� Q N Q C s 4 T rz *_r_rt NEW ENGLAND ENGINEERING SERVICES INC May 12, 1997 North Andover Board of Health Town Hall Annex School Street North Andover, MA 01845 33'7 RE: TITLE V REPORT = Dale Street Enclosed is the Title V report for 357 Dale Street, North Andover, MA. The system failed the inspection, however the Board of Health may determine that the system is protecting the public health and safety and the environment. If this is the case then the system would pass the inspection. Considering the above, I would like to request that the Board of Health review this file at its next Board meeting. The purpose of the review would be to determine that it is working. If there are any questions please call me at my office, 686-1768. Yours truly, B6n C. Osgood J., ..T. President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 IS '71i J�sl 01 1 1 1 1�4 IJ IL 1'. -1 -- - - s. IL 1'. -1 -- - - Town of North Andover, Massachusetts Form No. 3 pORTN BOARD OF HEALTH .s OO. 19 F 9 DISPOSAL WORKS CONSTRUCTION PERMIT SSACNuSE Applicant�/� NAMES ADDRESS TELEPHONE Site Location C:7 �� �/�GC + 57— e --45 ,/e L 7�4,C Permission is hereby granted to Construct ( ) or Repair (L --Kan Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CKIVIRMWN, WARDOFHEALTH Fee d;( D.W.C. No. EXCAVATION • TRUCKING - SEPTIC -FILL 1389 ... ....... ...... ....... ... . ...... .......... . .. . ... . ... ......... .... . . . . . . . . . . ............. . ...... ...... ..... ........... .. 'F t.__. .... . ............. ....... I ............ ... ........... . . i . .......... 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CALCULATED BY OF DATE- C04IT/94 r.wi:rKF:n Fty DATE . . ....... .. ..... ..... . . ....... ..... ... ­­ I -- . i . .... . ---- t I ... . ...... mAe .......... . . . . ........... ......... . ... ........... . . ...... ......... ............. ... . ............... ............ .. . ....... ............. .. ......... .......... .... ........ i -A OF, ......... ..... ..... . ..... ...... I ........... ... .... .... . ........... ........... .. .......... ............. ........ . ........... ......... ... ............. I ....... ..... ........... . ...— I................}.......::_...� ......... T J, ............ .. ......... .... ...... A . ....... Pmrnr?mLt rZFWPt� r- III— amn " i I ........... . ........... ............ . ............. ............ . ............. .............. ......... .... .............. " i I ........... . ........... TO D T ) TIME AM d�5 PM H O N FROM AR A C DE NO. EXT. OF E E s4E M s E s , MG E Q SIGNED PHONED ❑ CAALLLK E]CALL RETURNED 0 SEE WANTS ❑ AWILL GAIN ALL ❑ WAS IN El [URGENT ❑ Applican Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 G� 19� APPLICATION FOR SITE TESTING/INSPECTION UJ Site Location '�) 5-1 'A . l Engineer Test/Inspection Date and Time q� oa Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 6�� 6 0� �f g . �tiRAo�° Ew'oP : APPLICATION FOR SITE TESTING/INSPECTION Applic Site Location Engineer ' -.� ��'lA `` �;�,"✓��'U1 �n-`ti� �``�'�' �( NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. _ r) K S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. SEPTIC SYSTEM INSPECTION FORM ADDRESS i b-l-lV �Q DATE INSPECTED S`@ PROPERLY FUNCTIONING? d N WEATHER CONDITIONS COMMENTS: WA I ER QUAL! T Y TES! Zn ? JZEsOLTS? 'DYE TEST PERFORMED? Y N DATE? SKETCH: a WATERSHED RESIDENTS QUESTIONNAIRE 1. Name E' wtrri -1 LE/� k ZL 2. Street AddressZ 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool Vseptic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes Cvj� no ❑ do not know _ . 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years 9 over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? We yes ❑ no ❑ do not know If yes, approximately how long ago?— years. What was done? 8. How frequently is your sewage disposal system pumped out? annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes W' no If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine _ i dishwasher I_ garbage disposal I dehumidifier drain sump pump toilet 13_ roof/pavement drains shower/bathtub 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher CA s eA.i g- (qtr) clotheswasher 12. Does your property have a lawn? R( yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre © 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? No. of applications per year / Season(s) of the year _5p e, 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor.