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Miscellaneous - 357 RALEIGH TAVERN LANE 4/30/2018 (2)
r I North Andover Board of Assessors Public Access 4 y -r* t NORDT1i q Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 MEL AQProperty Record Card Location: 357 RALEIGH TAVERN LANE Owner Name: CRONIN, CHERYL L Owner Address: 357 RALEIGH TAVERN LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7 - 7 Land Area: 1.01 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1182 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 371,800 369,100 Building Value: 146,100 143,400 Land Value: 225,700 225,700 Market Land Value: 225,700 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1708476&town NandoverPubAcc 6/14/2011 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin. Owner's Name North Andover City/Town MA 01845 State Zip Code 6/9/2013 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Peter F. Reilly Name of Inspector same Company Name 136 Andover Street Company Address Andover MA City/Town State 978-375-3750 S11955 Telephone Number B. Certification License Number JUN 10 2013 OF NORTH ANDOVER LTH DEPARTMENT 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/9/2013 Ins tor' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This_r only describes conditions at the time of inspection and under the conditions of use ,E!Ve t tim .This inspection does not address how the system will perform in the future under same r different conditions of use. Jti�� "► 0 2013 t5ins - 1 �N OF NORTH ANDOVER O\NHEALTH DEPARTMENT Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleioh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover MA 01845 6/9/2013 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 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: It is noted that this is a 40 plus year old original system and the inspector makes no warranty as to how lonq it will remain viable. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover MA 01845 6/9/2013 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ ❑ obstruction is removed ❑ Y distribution box is leveled or replaced Y ❑ N 0N ❑ E] 11 6 ND (Explain below): N (E Iain below): �! ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 6/9/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 'h day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 6/9/2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o M 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code C. Checklist 6/9/2013 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No E ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 t5ins . 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 6/9/2013 every page. City/Town D. System Information Description: State Zip Code Date of Inspection Water meter readings, if available t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gpd)): 100 gpd avg. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 6/9/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date owner - last Dumped in June of 2011 gallons ❑ Yes ® No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 6/9/2013 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: The house was reportedly constructed in 1971. BOH records indicate that this is an original system. The d -box was replaced in July of 2011. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 12" - 14" feet Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): The building sewer was watertight and was functioning properly. Septic Tank (locate on site plan): Depth below grade: Material of construction: 8" - 10" feet ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) Rectangular 1,000 gallon tank. Tank was watertight and appeared to be functioning properly. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 5' x 10' Sludge depth: 1" - 2" t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 6/9/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 16"- 18" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" - 7" Distance from bottom of scum to bottom of outlet tee or baffle 15" - 16" How were dimensions determined? measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover MA 01845 6/9/2013 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The 1000 gallon septic tank was watertight. Concrete baffles were in place and functioning properly. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No Alarm in working order: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleiah Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover MA 01845 6/9/2013 City/Town D. System Information (cont.) State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Six lines leaving d -box were accepting effluent fairly evenly. Little solids carryover was evident. The box cover was 6" - 8" below the surface. The box was replaced in July of 2011 with an H-20 box. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 6/9/2013 every page. City/Town D. System Information (cont.) Type ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: State Zip Code Date of Inspection number: number: number: number, length: number, dimensions: 1 field, 6 lines, est. size 900 s.f. number: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Six lines, estimated size of SAS is 900 s.f. No dampness in the soils or ponding. Decent flow rate but the reader is cautioned that this is a 40+ year old original system in a house with only one occupant. It is noted that the inspection reflects the conditions at the time of the inspection. The inspector makes no judgment as to how lonq this system will remain viable. Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is . required for North Andover MA 01845 6/9/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form > ' 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.� . _ 9 p Y rY =" 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin OwnerOwner's Name _...._...____.._--- .._.____....._...___.....___.___.__ information is required for North...Andover MA 01845 6/9/2013 _._._ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. Q hand-sketch in the area below drawing attached separately App, Water HOUSE r i 1000 Gallon Septic Tank REAR f, YARD— D- I � l ; 3 SAS 1 SEPTIC TANK TIES: A to Inlet (1) 217" B to Inlet (1) 30A" A to Outlet (0) 266" B to Outlet (0) 266" D -BOX TIES: A to Box 358" B to Box 365" NOTE: The system is in the rear yard. D -box cover is about 6"-8" below the surface (following the replacement of the d -box). SAS size is 900 square feet per 1973 plan on file at BOH, Note that the BOH plan does not show the d -box or lines or the lines in the SAS. Referenced plan is attached. Photo of replacement d -box and lines leaving the box is attached as well. Also note that replacement H-20 box cover was about 6"-8" below surface. thins W13 Title S tHICAI, Inwe n kor n D:c nasal Sym Err; - I, Age of 1' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA every page. City/Town State D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 01845 6/9/2013 Zip Code Date of Inspection Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: —01 1 Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ® Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: No design plans available. No wet areas nearby. There is no sump pump in the dwelling. However, the precise ground water elevation cannot be determined without a soil evaluation test (see attached Addendum). Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 r' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 6/9/2013 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Peter F. Reilly Inspector June 9, 2013 1973 PLAN ON FILE AT BOH (Note: does not show d -box and SAS lines) 44 O. Z.4 7 =- �, 4C/JC•'.�IiNL j 7Yk.6A-� ab'o'!� t I� rA I00� GAG. SEIyjlc rA.lK � 1 _ 1 , { j PA LEI G.H "T—.-vL t .t`i. L./ -\r4 F. (Sou'r1.1),I i CA- .)" . a' PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division TICA2TA-p OT C09V(PLJ Asof. ju,f y 12, 2011 This is to cert that the individuafsu6surface disposal system received a SATIS FACTORT INSTECTION of the: Instalration of an M-20 Oi striktion Boal for an On Site Sewage OlisposaCSystem By: hfike dilly At: 357 Ceiqh Tavern Lane 911ap-10 7.A ~2'arceC-0123 North Andover, 90 01845 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Z'i't ��dan '�-. Sawyer - 14U cft6Cu?leaCth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 fax 918.688.8416 Web www.townofnorthandover.com • Qt °`4R7`Commonwealth of Massachusetts Map-Block-Lot 107.A0123 BOARD OF HEALTH ----------------------- �� Permit No V00 4 i_ North Andover BHP -2011-0741 �' �.. 1j .e ♦" + P.I. �� �' •.,P �,'q�F FEE 5 ACNUG F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Mike Reilly ------------------------------------------------------------------------------------ to (Repair -DISTRIBUTION BOX ONLY) an Individual Sewage Disposal System. at No 357 RALEIGH TAVERN LANE as shown on the application for Disposal Works Construction Permit No. BHP -2011-074 Dated July -05,201-1 Issued OJul-OS-2011 ------------------------------- -- BOARD OF HEALTH .. 55b; 1 NGRTH 1� f • � v 10 9 P Town oflVorth Andover HEALTH DEPARTMENT SACMUSt T CHECK #: 52�ZDAT O, LOCATION: H/O NAME: 0 CONTRACTOR N Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ 1 Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑S'c - Design Approval $ !� Septic Disposal Works Construction (DWC) $O ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer o. slue Medicare PFFS (Blue Cross Blue Shield of MA) Fallon Senior Plan (Fallon Community Health Plan) First Seniority Freedom (Harvard Pilgrim Health Care) Senior Whole Health Tufts Health Plan Medicare Prefei (Tufts Health Plan) Medicare Card Number # I give permission to bill my insure (Signature of person to receive vaccine X For Clinic/Office Use: I Vaccine namerC.Laii Injection site:�c::ti-_ (1 Date 1 JVaccine manufacturer: C�(��L�±I " Name and title of vaccine administrator: Clinic/office address: L Influenza Forms — MAHP/Masspro Plan Reimburserr -5 Jul 01 11 01:03p Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab F.P. Reilly & Sons 9784753102 Application for Septic Disposal System Construction Permit -TOWN OF 1'I Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* P.1 10), TOD Y'S DATE $ 250.00 — Full Repair $125.00 -Component ❑ Repair or replace an existing on-site sewage disposal system* UAepair or replace an existing system component— What? A. Facility Information Address or Lot # ,ey Kh :r l-' cityrrown 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump 7 Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Siodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information n. Name J �r •�.�, .ten i .. r Address (if different from le -1 e) `1 Cityrrowrn State /f �r Zip Code 4. Telephone Number 3. Installer Information & i f 1-7 Cl e. f Name Name of Company Address ��='� ii✓;� Jam` (�i 0 Cityrrown State �- Zip Code Telephone Number (Cell Phone # if possibfe please) 4. Designer Information Name Name of Company Address CitylTown State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page t of 2 Jul 01 11 01:03p At F.P. Reilly & Sons 9784753102 Application for Septic Disposal System (Construction Permit -TOWN OF MA 01845 PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: (Residential Dwelling or ❑Commercial B. Agreement p.2 r � TODAY'S DATE $ 250.00 –Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Soa(d of Health. Name—T Date Application pproved By: oared of Health Representativ o 1i Name { ' � Date A�/plica on Disap roved forKefolicwing reasons: For Office Use Only: L Fee Attached? Yes 2. Project Manager Obligation Form Attached? Yes I Pump System? If so, Attach c profFlectricalPermit Yes 4. Foundadan As -Built--' (new construction ronly): Yes (Same scale as approv4d plan) 5. Floor Plans? (new n only): No No No � I Application fo j Disposal System Construction Permit • Page 2 of 2 Oe s TOWN OF ANDOVER HEALTH DIVISION SUBSURFACE DISPOSAL SYSTENUSEPTIC REPAIR PERMIT APPLICATION Site Address: 7,5 7O/, 1//t 7 Z Date: Town Map: Town Lot: . Owner Name: 6—r'/iii Address: Jam' 7 �h Tgvll•, Lh, IV 4' Telephone:L7 8 ❑ New Construction ❑ Existing Facility 'Repair of Existing Septic System — Describe: Is an LUANariance required? If Yes, please list:. Yes I I No Installer Name: A,1 G hOa & L'/f� Address: G '4/ov/yy� a v e *7 IS 7 Engineer: Address: Telephone: Fac ity Type: Dwelling: # of Bedrooms ❑ Food Service: # of Seats: ❑ Exterior Grease Trap Size: V, The undersigned agrees to construct the approved sewerage system in accordance with the requirements set forth in the Board of Health Regulations AND Title V, 310 C.M.R 15.000. Disposal Works Installer's Signature: Date: Attached: ❑ 5 Copies of Design Plan ❑ Sketch Showing Tank Location (for repair) ❑ Application Fee For Office Use Only: Page l Created 10/16/2008 Date Received Date Issued ADDroved by_ Permit # DWAP DWCP DWIP DWRA DWRP Certificate of Compliance Page l Created 10/16/2008 Address: Plan Date: SUBSURFACE DISPOSAL SYSTEM STAFF REVIEW AND APPROVAL Town Map Date Distributed: Town Lot Subdivision Lot Revision? ❑ Yes ❑ No Sent to The Conservation Commission Recommends the Following: ❑ No action required. ❑ Applicant must submit Request for Determination. ❑ Applicant should file Notice of Intent ❑ Plan conforms to plans approved under existing Order of Conditions #90- ; no further action required. ❑ Plan does not conform to plans approved under existing Order of Conditions #90- ❑ Applicant should file written request as to whether changes require a new filing or amendment of the Order of Conditions OR ❑ Changes proposed appear to have reduced impact on statutory interests and may proceed without further action, provided that an As -Built drawing accompanies the Designer's Certification and the request for a Certificate of Compliance from the Commission. Signed: Date: Notice: This report is not an assurance of quality or compliance, and third parties, including applicants, are not entitled to rely thereon. ❑ Sent to The Health Agent recommends the following: ❑ Approval ❑ Disapproval for the following reason(s): Signed: Date: ❑ Sent to The Director of Public Health recommends the following: ❑ Approval ❑ Disapproval for the following reason(s): Date: INSPECTION NOTES: Date: Details: Inspector Signature: Page 2 Created 10/16/2008 North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORM. IQN ADDRESS: `, ���1 MAP: LOT: INSTALLER:( �I DESIGNER: PLAN DATE:I1 BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port Comments: ull� n� ll s i„- (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement F-1Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) [✓� Hydraulic cement around inlet & outlets ❑�Observed even distribution Z Speed levelers provided (not required) Comments: ull� n� ll s i„- SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS -excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral INVERT Lateral 4 TOP Lateral INVERT Lateral 5 TOP Lateral INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN 0 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback I ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® 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 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 I ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws a Commonwealth of Massachusetts W\\�Title 5 Official Inspection For CE� Subsurface Sewage Disposal System Form -Not for VoluntaryAss sm LA 2011 w 357 Raleigh Tavern Lane''�� Property Address HE11L7?I DEPARTEMNT Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18 2011 every page. City/Town State Zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rad return Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Peter F. Reill Name of Inspector Peter F. Reilly Company Name 136 Andover Street Company Address Andover City/Town 978-375-3750 Telephone Number B. Certification MA State S11955 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ NAFurthnEvaluation by the Local Approving Authority June 18, 2011 I pec Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1,000 gallon septic tank / d -box / SAS (field). Original system installed in 1973 according to plan on file at BOH. D -box replaced in 1996. Number of current residents: Does residence have a garbage grinder? 1 0111IM �/EM. Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 100 gpd avg. 9 ( Y 9 (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code June 18, 2011 Date of Inspection Approximate age of all components, date installed (if known) and source of information: original system installed in 1973 per plan on file at BOH. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 1211- 14" feet Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer was watertight and appeared sound at the foundation. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No 8" - 10" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 6' x 12' Sludge depth: 1-1-211 t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D - SYSTEM INFORMATION (continued) Property Address: 357 Raleigh Tavern Lane, North Andover Owner's Name: Cheryl L. Cronin Date of Inspection: 6/18/2011 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. N/A Locate where public water supply enters the building. App Water HOUSE 1000 Gallon Septi c Tank REAR YARD a ,,.BOX SAS SEPTIC TANK TIES: A to Inlet (1) 2171 B to Inlet (1) 3014" A to Outlet (0) 2616" B to Outlet (0) 2516" D -BOX TIES: A to Box 368" B to Box 3615" NOTE: The system is in the rear yard. D -box cover is about 6%8" below the surface (following the replacement of the d -box). SAS size is 900 square feet per 1973 plan on file at BOH. Note that the BOH plan does not show the d -box or lines or the lines in the SAS. Referenced plan is attached. Photo of replacement d -box and lines leaving the box is attached as well. Also note that replacement H-20 box coverwas about 6"-8" below surface. 1973 PLAN ON FILE AT BOH (Note: does not show d -box and SAS lines) ©ti -r-<fr- UlAb3 PHOTO OF D -BOX AND LINES (Taken After Box Replacement) =i .t L_ Ate) = , vS • r" . _ ' �„"' ""' 'r.+ .e�; J4 x " Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab remm Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover City/Town ientsju TON NOgTH 0 MA 01845 June 18, 2011 s 11110 State Zip Code Date of Inspection I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Peter F. Reill Name of Inspector Peter F. Reilly Company Name 136 Andover Street Company Address Andover City/Town 978-375-3750 Telephone Number B. Certification MA 01810 State Zip Code S11955 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature June 18, 2011 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): The system will pass once the broken and deteriorated d -box is replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑ 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 '/2 day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. CityFrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1,000 gallon septic tank / d -box / SAS (field). Original system installed in 1971. D -box replaced in 1996. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No 100 gpd avg. ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 357 Raleigh Tavern Lane Owner information is required for every page. Property Address Cheryl L. Cronin Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 June 18, 2011 State Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: currently occupied Date BOH (last pumped 9/17/2007 gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system installed in 1971. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 12" - 14" feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer was watertight and appeared sound at the foundation. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 811-101, feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 6' x 12' Sludge depth: 1"-2" — t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover every page. City/Town State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 28" 1"-2° 8" 16" June 18, 2011 Date of Inspection How were dimensions determined? measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was watertight and appears to be functioning properly. The owner reportedly had the tank pumped following the inspection. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness N/A feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 11/10 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 June 18, 2011 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a 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.): Six lines leading to SAS were accepting effluent fairly evenly. Minimal solids carryover evident. The box cover was 10" - 12" below the surface. The d -box was severely deteriorated and needs to be replaced. The inspection is a "conditional pass" until the box is replaced. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for every page. t5ins • 11/10 North Andover MA City/Town State D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields 01845 June 18, 2011 Zip Code Date of Inspection number: number: number: number, length: number, dimensions: 6 lines approx. 900 s.f. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils in the area of the SAS appeared normal, no signs of breakout. Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover City/Town D. System Information (cont.) MA State n1AAr) Z -1N %,UUU June 18, 2011 Date 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.): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover MA 01845 June 18, 2011 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 357 Raleigh Tavern Lane, North Andover Owner's Name: Cheryl L. Cronin Date of Inspection: 6/18/2011 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. N/A Locate where public water supply enters the building. APP. WATER HOUSE A 1000 Gallon Septic Tank k...B R EAR YARD SAS SEPTIC TANK TIES: A to Inlet (1) 2117" B to Inlet (1) 3014" A to Outlet (0) 2616" B to Outlet (0) 2516" D -BOX TIES: A to Box 368" B to Box 3615" NOTE: The system is in the rear yard. D -box cover is about 10"-12" below the surface. SAS size is 900 square feet per "as built" plan. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: MA 01845 State Zip Code June 18, 2011 Date of Inspection <1" below bottom of SAS feet Please indicate all methods used to determine the high ground water elevation: 0 �41 // 4/ // Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: information on file. Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: USGS data not specific to site. You must describe how you established the high ground water elevation: Soils, grade changes, and lack of sump pump indicates adequate groundwater separation. Howwever, the precise ground water elevation cannot be determined for certain without a soil evaulation test. NOTE: Soil evaulation is the recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaulator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified septic system inspector. (see attached Discliamer) Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified underTitle V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. .)�A Peter F. Reilly Inspector June 18, 2011 G . -T,� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 Raleigh Tavern Lane Property Address Cheryl L. Cronin Owner Owner's Name information is required for North Andover MA 01845 June 18, 2011 every page. CityTTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 ti DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Monday, July 11, 2011 1:46 PM To: 'cheyl cronin' Subject: RE: I.R. - 357 Raleigh Tavern Lane - Scanned Health Dept. File You are welcome. The permit was picked up this morning by Peter Reilly for Mike Reilly. SW Rgaada, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA o1845 `d Office - 978-688-9540 Fax - 978-688-8476 I Email - pdellechiaie(@townofnorthandover.com -2S Website hM://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "� Anonymous From: cheyl cronin jmaiIto: cicronin3500hotmail.coml Sent: Monday, July 11, 2011 1:21 PM To: DelleChiaie, Pamela Subject: RE: I.R. - 357 Raleigh Tavern Lane - Scanned Health Dept. File Hi Pamela ---THANK YOU!!!!!!!!!!!! C From: pdellech(&townofnorthandover.com To: cicronin350hotmail.com CC: fpreillyandsonsC9bcomcast.net; ssawyer townofnorthandover.com Date: Fri, 8 Jul 2011 14:37:33 -0400 Subject: FW: I.R. - 357 Raleigh Tavern Lane - Scanned Health Dept. File Hello Cheryl, Per our conversation this morning, I just wanted to let you know that I left a message for Mike Reilly letting him know that his permit to replace your d -box is all set. I received the Title S report yesterday, and Susan Sawyer reviewed it, and so it is all set to move forward. Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA o1845 2 Office - 978-688-9540 ( Fax - 978-688-8476 D Email - pdellechiaieotownofnorthandover.com `8 Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous From: DelleChiaie, Pamela Sent: Tuesday, June 14, 20113:16 PM To: 'cicronin35@hotmail.com' Subject: I.R. - 357 Raleigh Tavern Lane - Scanned Health Dept. File Importance: High To: Cheryl Cronin -357 Raleigh Tavern Lane 978.686.8665 Dear Cheryl, Attached is the information you requested for your residence at 357 Raleigh Tavern Lane. I scanned the complete file, so you will have the complete record, and print what you need for the Title 5 Inspector. Please call the Health Department if you have any further questions. Enjoy your day! -- MW Rqa% 4, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA o1845 it Office - 978-688-9540 R Fax - 978-688-8476 0 Email - 12dellechiaie(@townoftiorthandover.com '6 Website bM://www.townoffiorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous If you are happy with the customer service you have received from town departments, please let us know ...Jeel free to complete the general Comment Form (link below): htto://www.townofnorthandover.com/Pages/NAndoverMA WebQocs/contact Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: httu://www.sec.state.ma.us/ore/areidx.htm. Please consider the environment before printing this email. DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Tuesday, June 14, 20113:16 PM To: 'cicronin35@hotmail.com' Subject: I.R. - 357 Raleigh Tavern Lane - Scanned Health Dept. File Attachments: 20110614143506081 Importance: High Follow Up Flag: Follow up Flag Status: Flagged To: Cheryl Cronin 357 Raleigh Tavern Lane 978.686.8665 Dear Cheryl, Attached is the information you requested for your residence at 357 Raleigh Tavern Lane. I scanned the complete file, so you will have the complete record, and print what you need for the Title 5 Inspector. Please call the Health Department if you have any further questions. Enjoy your day! -- Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg zo ! Suite 2-36 North Andover, MA o1845 2 Office - 978-688-9540 Fax -978-688-8476 D Email -pdellechiaie(@townofiiorthandover.com '16 Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous If you are happy with the customer service you have received from town departments, please let us know ...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact Town of North Andover, Massachusetts Form No. 3 t Na oTH BOARD OF HEALTH d19o �''��,,.o.�•'� DISPOSAL WORKS CONSTRUCTION PERMIT ,SS�ICHUSES Applicant Site Local Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee �i CHAIRMAN, BOARD OF HEALTH D.W.C. No. �� Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that 0 , July 29, 1996 the components of the individual subsurface disposal system (D -box) repaired by Kenneth Rea, installer, at 357 Raleigh Tavern Lane, North Andover has been installed in accordance with the provisions of TITLE S of the State Sanitary Code and with local Board of Health regulations. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. 1�1-j& A62 -7v $9axd of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover. MA -5-g NST" Watershed Septic System SO`NpaRQ OF H���tH Servicing Report Date: 5-0917W Homeowner: P& 413 Ls i a(a. A-) Pumper Street IC k �,U(.,c�, Address: ?0( LZK /Q.24 Phone .��'f- li �� _�o�` Phone Nature of Service: Observations: Routine Emergency Good Condition Full ;to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) Descri tion of Work: N r � Comments: RAGGS, INC. Subsurface Soil Disposal Inspection Report In Accordance With Title 5 (310CMR 15.000) e,�ng you Since P. O. Box 1027, Concord, MA 01742 (508) 369-1100 / (800) 287-5541 FAX (508) 897-3848 RAGGS, INC., P. O. Box 1027, CONCORD, MA 01742 (508) 369-1100 OFFICIAL CERTIFICATION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION IN ACCORDANCE WITH TITLE 5 (310 CMR 15.000) CERTIFICATION PREPARED FOR: Paul and Doris Polatin ADDRESS OF PROPERTY DATE OF INSPECTION: RESULTS: 357 Raleigh Tavern Lane North Andover; MA 01845 May 29, 1996 This property has PASSED the criteria set forth in 310 CMR 15.000. This property has CONDITIONALLY PASSED the criteria set forth in 310 CMR 15.000. This property has NEEDS FURTHER EVALUATION BY THE BOARD OF HEALTH according to the criteria set forth in 310 CMR15.000. This property has FAILED the criteria set forth in 310 CMR 15.000. RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (506)369-1100 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM ADDRESS OF PROPERTY: 357 Raleigh Tavern Lane North Andover, MA 01845 OWNER'S NAME: Paul and Doris Polatin DATE OF INSPECTION: May 29, 1996 PART A CERTIFICATION Name of Inspector: Wendy Diotalevi, R. S. Company Name: Raggs, Inc. Company Address: P. 0. Box 1027, Concord, MA 01742 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY CONDITIONALLY PASSES FAILS Inspector's Signaturb aWendy Diotalevi, Registered Sanitarian #942 11 11 1 ul ate Raggs, Inc.. certifies that all work performed on the aforementioned property was done in accordance with the guidelines set forth in Title 5 (310 CMR 15.303). Fred T. Fish, President Raggs Septic Service, Inc. d/b/a E. A. Comeau File No.: 96-10815/POLATINPAU Copies to: Payer of inspection Local Board of Health or its agent Date D is D RAGGS, INC., P.O. BOIL; 1027, CONCORD, MA 01742 (508)369-1100 96-10815/POLATINPAU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY A. System passes: have not found any information which indicates that the system violates any of the failure criteria as defined in 310CMR 15.303 Any failure criteria not evaluated are indicated below. B. System Conditionally Passes: X One or more system components need to be replaced or repaired. The system, aupon completion of the replacement or repair, passes inspection. I 0 i D u r! 1 I Septic tank is: Metal: Cracked: Structurally unsound: Substantial infiltration: Substantial exfiltration: Tank failure imminent: Tee(s) missing: The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. X Sewage backup or breakout or high static water level observed in the distribution box _ is due to a broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with the approval of the Board of Health): Broken pipe(s) are replaced: Obstruction is removed: Distribution box is levelled or replaced: YES 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: 2 J D RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 15081369-1100 96-10815/POLATINPAU SUBSURFACE SEW'AGE°DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY continued C. Further Evaluation Is Required By The Board Of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety, and the environment. 1. System will pass unless the Board of Health determines that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water: Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt amarsh: 2. System will fail unless the Board of Health (and Public Water Supplier, if aappropriate) determines that the system is functioning in a manner that will protect public health, safety, and the environment. D 0 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.: The system has a septic tank and a soil absorption system and is within a Zone 1 of a public water supply well.: The system has a septic tank and a 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 volitale organic compounds indicates that the well is free from pollution from that facility and that the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.: D ui I 1 l I RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100 96-10815/POLATINPAU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY continued D. System Fails: I have determined that the system violates one or more of the following failure criteria as defined in 310CMR 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 cesspool..- Liquid esspool.:Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.: Required pumping more than four 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, volitale organic compunds, ammonia nitrogen and nitrate nitrogen.: ki D I u a r u i y RAGGS, INC., P.O. BOX 1027, CONCORD, IIIA 01742 (508)369-1100 96-10815/POLATINPAU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY continued E. Large System Fails: The following criteria apply to large systems in addition to the citeria listed above: The design flow of the system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health, safety and the environment because one or morer 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 li 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 requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department of Environmental Protection for additional information. k, y RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 15081369-1100 96-10815/POLATINPAU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST The following have been done - 1. Pumping information was requested of the owner, occupant, and Board of Health: Yes 2. 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: Yes E3. As -built plans have been obtained and examined: Yes a4. The facility or dwelling was inspected for signs of sewage back-up: Yes 5. The site was inspected for signs of breakout: Yes 6. All system components, excluding the SAS, have been located on the site: Yes 7. 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: Yes 8. The size and location of the SAS on the site has been determined based on existing information or approximated by non -intrusive methods: Yes 9. The facility owner (and occupants, if different from owner) were provided with information the proper maintenance of SSDS: Enclosed with report. C.1 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100 96-10815/POLATINPAU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS Residential: design flow: number of bedrooms: 3 number of current residents: 3 garbage grinder: yes laundry connected to system: yes seasonal use: no Water meter readings: see Appendix D private well: no Last date of occupancy: occupied Commercial / Industrial: Type of Establishment: n/a design flow: grease trap: industrial waste holding tank: non -sanitary waste discharged to the Title 5 system: Water meter readings: Other: n/a Last date of occupancy: Last date of occupancy: GENERAL INFORMATION Pumping records and source of information: see Appendix A; Homeowner System pumped as part of inspection: yes Volume pumped: 1,000 gallons Reason for pumping: Examination of the structural integrity of the tank. Tvge of system - Septic tank/distribution box/soil absorption system: yes Single cesspool: Overflow cesspool: Privy: Shared system: Other: Approximate age of all components: 23 years Date installed: 11/6/73 Source of information: As -Built Plan Sewage odors detected when arriving at the site: no 7 RAGGS, INC., P.®. BOX 1027, CONCORD. MA 01742 (508)369-1100 a96-10815/PO LATI N PA U a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued TANK locate on site Ian -- see page 11 and Appendix B SEPTIC T ( plan) p 9 Depth below grade: .8' Material of construction - Concrete: X Metal: FRP: Other.- Dimensions: ther: Dimensions: 8'X 4'X 5' Sludge depth: .8' Distance from top of sludge to bottom of outlet tee or baffle: 2.7' Scum thickness: .7' Distance from top of scum to top of outlet tee or baffle: A' Distance from bottom of scum to bottom of outlet tee or baffle: 1.2' Recommendation for pumping: annually Condition of inlet and outlet tees or baffles: inlet -intact; outlet baffle only Depth of liquid level in relation to outlet invert: level Structural integrity: good Evidence of leakage: none Recommendation for repairs: No tee was on outlet, only a baffle was present. Solids are getting into d -box. Recommend installation of outlet tee. GREASE TRAP (locate on site plan) -- n/a Depth below grade: Material of construction - Concrete: Metal: FRP: Other: 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: Recommendation for pumping: li Condition of inlet and outlet tees or baffles: Depth of liquid level in relation to outlet invert: Structural integrity: Evidence of leakage.- Recommendation eakage:Recommendation for repairs: 0 8 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 15081369-1100 96-10815/POLATINPAU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued TIGHT OR HOLDING TANK (locate on site plan) -- n/a Depth below grade: Material of construction - Concrete: Metal: FRP: Other: Dimensions: Capacity: Design flow: Condition of inlet tee: Condition of alarm and float switches: Recommendations: Alarm level: DISTRIBUTION BOX (locate on site plan) -- see page 11 and Appendix B Depth of liquid level above outlet invert: zero Level and distribution are equal: yes Evidence of solids carryover: yes, 6" of solids Evidence of leakage into or out or box: yes, severely corroded; cover - broken Recommendation for repairs: replace d -box and waterjet lines PUMP CHAMBER (locate on site plan) -- n/a Pumps in working order: Condition of pump chamber: Condition of pumps and appurtenances: Recommendation for maintenance or repairs: 9 E RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (608)369-1100 n96-10815/POLATINPAU a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued aSOIL -- see page 11 and Appendix B (locate on site plan, if possible; excavation not required, but may be approximated by non - intrusive methods). PIf not determined to be present, explain: aRecommendations for maintenance or repairs: aPRIVY(locate on site plan) -- n/a Materials of construction: aDimensions: Depth of solids: Condition of soil: Signs of hydraulic failure: aLevel of ponding: Condition of. vegetation: Recommendations for maintenance or repairs: 10 Type: Leaching pits and number: Leaching chambers and number: Leaching galleries and number: D Leaching trenches, number, length: Leaching fields, number, dimensions: 900 square feet Overflow cesspool, number: Condition of soil: normal Signs of hydraulic failures: none Level of ponding: none Condition of vegetation: normal Recommendations for maintenance or repairs: distribution laterals have slime mold build-up - recommend waterjetting aCESSPOOLS (locate on site plan) -- n/a 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) Condition of soil: Signs of hydraulic failure: Level of ponding: Condition of vegetation: aRecommendations for maintenance or repairs: aPRIVY(locate on site plan) -- n/a Materials of construction: aDimensions: Depth of solids: Condition of soil: Signs of hydraulic failure: aLevel of ponding: Condition of. vegetation: Recommendations for maintenance or repairs: 10 0 0 0 0 0 0 0 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100 96-10815/POLATINPAU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM * Include ties to at least two permanent references, landmarks or benchmarks *Locate all wells within 100 ft. 3 3s7 ��KC�GN%vERNLN in ;<+C.E/G-H -7;; vee�j LSE DEPTH TO GROUNDWATER: More than 6' METHOD OF DETERMINATION OR APPROXIMATION: A test hole was probed during inspection of distribution box to a depth of approximately 6'. No groundwater infiltration was noted. RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (5081369-1100 96-10815/POLATINPAU APPENDIX A: HISTORICAL PUMPING RECORDS, REPAIR RECORDS 12 RAGGS, INC., P O BOX 1027, CONCORD, MA 01742 (508)369-1100 96-10815/POLATINPAU 357 Raleigh Tavern Lane, North Andover, MA 01846 Prior to inspection, system was pumped 2.5 years ago. Source of information: Homeowner 13 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100 96-10815/POLATINPAU APPENDIX E: SITE PLAN / AS BUILT PLAN 14 . srmoo... . �J LOT 3 G l l 44 ,. 2 4 7 =- 1E: T 44/�. Nr,. - /67.06 �Z AL E"-�—` CA a w N oclCc- «//1/73 T2 EE Po 'S E R -am va-D 2✓: G cij.";'ii N G � i l:.r. (.n "� �J b":o'I�r 1 1E: T 44/�. Nr,. - /67.06 �Z AL E"-�—` CA a w N oclCc- «//1/73 RAGGS, INC., P.O. BOX 1027, CONCORD, AVIA 01742 15081369-1100 a96-10815/POLATINPAU I i i 11 D D p i D 11 APPENDIX C: LISTING SHEET n15 n RAGGS, INC., P.O. SOX 1027, CONCORD, MA 01742 (508)369-1100 96-10815/P 0 LATI N PAU 357 Raleigh Tavern Lane, North Andover, MA 01846 aNo listing sheet was available for this property. a a a 0 a 0 0 0 0 0 0 n16 RAGGS, INC., P.O. SOX 1027, CONCORD, MA 01742 15081369-1100 96-10815/POLATINPAU Appendix D: Water Usage Documentation 17 RAGGS, INC., P O BOX 1027, CONCORD, MA 01742 15081369-1100 96-10815/POLATI N PAU F 357 Raleigh Tavern Lane, North Andover, MA 01946 3/02/94 - 230,500 1/17/96 - 251,700 im IZAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (503)369-1100 96-10815/POLATINPAU Appendix E: Recommendations: Repair, Pumping, & Maintenance ik RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100 96-10815/POLATINPAU Recommendations for 357 Raleigh Tavern Lane, North Andover, MA 01846 1. Replace distribution box. 2. Waterjet lines. 3. Install outlet tee. 4. Pump system annually. 20 11 ng you Since00 4GGS 1"S General Maintenance Recommendations Proper maintenance of your septic system can help prevent premature failure of your soil absorption system. RAGGS, INC. recommends the following: DO PUMP your system ANNUALLY. DO OPEN your D -Box every THREE TO FOUR YEARS. DO ensure that your VENT PIPES are installed properly. DO make sure you know where your TANK is LOCATED. DO make sure you know where your LEACHING FIELD is LOCATED. DO look for GREEN STRIPES over leaching field. DO check to determine if you can smell any ODORS from field location. DO bring your COVERS WITHIN 6" OF GRADE. DO USE LIQUID DETERGENT. DO USE NON-ABRASIVE HOUSEHOLD CLEANING PRODUCTS. DO USE ENVIRONMENTALLY SAFE PRODUCTS. DO INSTALL WATER SAVING DEVICES, where appropriate. DO USE SMALL AMOUNTS OF BLEACH when cleaning toilets, etc. DO AVOID having roof gutters and downspouts DRAIN ONTO the LEACHING FIELD. RAGGS SEPTIC SERVICE, INC. d.b.a. E.A. COMEAU SEPTIC P.O. Box 1027 Concord, Massachusetts 01742 (800) 287-5541 (508) 369-1100 FAX (508) 897-3848 r ung you Since >. 06 `gGGS ills General Maintenance Recommendations (con'd) DON'T DISPOSE anything NON -BIODEGRADABLE IN TOILETS. (i.e.: cigarettes, sanitary napkins, diapers) DON'T wash paint brushes used in latex or oil PAINT. DON'T allow any PAINT, THINNERS, OR ANY OTHER TOXIC OR CAUSTIC LIQUIDS to go down sink or toilets. DON'T allow ANY GREASE or FAT to enter system. DON'T DISPOSE BONES, EGG SHELLS, COFFEE GROUNDS,OR FIBROUS MATERIAL, etc. when using a garbage disposal DON'T use powdered detergents with phosphates. DON'T use any DRAIN CLEANERS. DON'T use any ENZYMES. DON'T use any GREASE DISSOLVERS. DO NOT ADD ANY ADDITIVES TO YOUR SYSTEM FOR ANY REASON. In the event of a clog or other plumbing problem, contact your local plumber, rooter or pumper. DON'T PLANT any trees or shrubs WITHIN 10 FT. OF THE LEACHING FIELD. DON'T ALLOW SPRINKLER SYSTEMS or other WATERING DEVICES OVER THE LEACHING FIELD. DON'T DRIVE any VEHICLES or place any HEAVY OBJECTS ON TOP OF THE LEACHING FIELD. DON'T INSTALL a swimming pool, a patio, or a driveway over the tank or leaching field. EDON'T CONNECT a basement sump pump to a household drain. C j RAGGS SEPTIC SERVICE, INC. �j d.b.a. E.A. COMEAU SEPTIC P.O. Box 1027 Concord, Massachusetts 01742 (800) 287-5541 (508) 369-1100 FAX (508) 897-3848 1� Y.Sor -11, 4 Lo -r .3 e. 4q , Z 4 7 ---- 44' / \ t.... �. I � �`"'� �+ �p� l Y� 1...� 1''•-., t 1 I r� i F�� � ��..eqV i— l' 3 � f� { t Oj / -6�L 1114b3 T2 EE To '� E ,ea.,ov¢a _ Zoe 44' / \ t.... �. I � �`"'� �+ �p� l Y� 1...� 1''•-., t 1 I r� i F�� � ��..eqV i— l' 3 � f� { t Oj / -6�L 1114b3 f f/O,e l —a6 F3t��cG I "f nu F 15U ; LCO. !-,l.• (' f3g 7- ;( �✓ t� L &'�) c psi ,G;� ,� �..-.� y�J �7� CK (= 1LC r � 0 WASH F: D, �TJtwo r 'GG ! r J G a o u S �°�•%�/ � BV/RC1 r'tircF' f' IPS"��j I 5 i A/oT E: i f lee- no a ,.1 P/ -,OV a,< a " 7 vim/ „� .� crC. v.• lj �,� O'�: « /J N f D %EJ�2ACE „✓Tri r`jA�JC G0. 40 �` M b a o c vp "�._j o,�.7� `� \ ,rte . '�F.•• . 0 O ..46 a � • .,,- o ti 1 ♦ O • ar • G • ' '� � r CO En,J :5 T v APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I her y make ap lication for a permit for a sewage disposal installation at /,� I will install this system in ac- cordance with all the laws o the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of %_S a in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of �_. &— lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE 7/ gnature of Applic I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE //-/)--7/ Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer Percolation Test 4" Garbage Grinder BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. f �4- 1 . NAME / v c° 1?f / �O.�G°�C iC"E�` � GSIDATE �✓��� 2. ADDRESS �Wel;(r L7 /��Ge� ����� LOT NO. G TEL. 7S 3. NO. OF BEDROOMS S/ DEN YES NO �- 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. Commonwealth of Massachusetts City/Town of W° System Pumping Record i4^M Form .4 DEP has provided this form for use by local Boards of Hea�tPf.CrIh�Ft'S d, but the information must be substantially the same as that provide' rm, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. Syste cation: Left front of house, right front of house, left side of house, right side of housaulD ar of h�ight rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Stat Zip�d. Telephone Number Date �eptic ntit Pumped: Cesspool(s) Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: kj,,AA--,:qA 6. System Pumped By: Neil J. Bateson �v Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: ler Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 �L\ Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record VPuAp4Aec( Form 4 DEP has provided this form for use by local Boards of Health. T ;.SysQebe submitted to the local Board of Health or other approving aut - GI 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 rman System Location: Address 0& J r � City/Town System Owner: C�•:� Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): AAA 01 Siate Zip Code State & Zip ^�Code Telephone Number D t—� 2. Quantity Pumped: Gallons Cesspool(s) 'Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes)(l No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 9 0cI 6. System Pumped By: `z Name < C Vehicle License Number r Company 7. Location where contents were disposed: Signature oti4aufetJ '/' http://www.mass.gov/dep/water/approvals/t5forms.htni#inspect Date must t5form4.doc• 06/03 System Pumping Record • Page 1 of 1