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HomeMy WebLinkAboutMiscellaneous - 36 SHANNON LANE 4/30/2018 (3)r 0 MAP # LOT # 3l0 PARCEL # STREET SJ69,- _\N_.�"1�_ (a -AA -e CONSTRUCTI_pN_APPR ....._.... . HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE Zlz /m APP. BY_� .._ DESIGNER: Li/�,E'I��T/�J/1/�5� PLAN DATE;_ / / /q,3 CONDITIONS _-_.--- WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER._..._.__._.__.._...__._...___..._ ........ _. __._._.._..........__...... WELL TESTS: CHEMICAL UAIE A{'RlZUVEU BACTERIA I UA I E (IPPRUVED BAC IA Ii DA i E COMMENTS FORM U APPROVAL: APPROVAL TU ISSUE 65) NO DATE ISSUED �� ��/3 BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL' YES N[.l OTHER Y NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DR TE: .q..IIY t � r 0 MAP # LOT # 3l0 PARCEL # STREET SJ69,- _\N_.�"1�_ (a -AA -e CONSTRUCTI_pN_APPR ....._.... . HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE Zlz /m APP. BY_� .._ DESIGNER: Li/�,E'I��T/�J/1/�5� PLAN DATE;_ / / /q,3 CONDITIONS _-_.--- WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER._..._.__._.__.._...__._...___..._ ........ _. __._._.._..........__...... WELL TESTS: CHEMICAL UAIE A{'RlZUVEU BACTERIA I UA I E (IPPRUVED BAC IA Ii DA i E COMMENTS FORM U APPROVAL: APPROVAL TU ISSUE 65) NO DATE ISSUED �� ��/3 BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL' YES N[.l OTHER Y NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DR TE: .q..IIY N N N II II II II II II I �o 0 ,o F v_ DRAWING N0. 94093002 \J \ V Y rn to Ito P300 Y . O v go '06 v O O k N ~ O � to � -i IOU nl i� r'1 r",�_ �_ 0 "0�_ �_ �_ Q y v r^ C O� y y 11 Cl) �Z �1 to to�1 N Z �► `r� Rl� ro Z (NrnO`<a y y W � iio y � tb O k co O k W O k W Orrl k c� c� ZO Z m Z n° o~ aZ��_ v o Z n a C Rl a Z C = a i Z a 2 2 2 r;� Z Z rte►, VN- LI) � cnr- y y y y o 2 v v v v �OMAy,��F9(� O CO �► Z Ln Z11 Z n v to �► co O O O O O v Oo ca ca 00 N y O~ g ni Z � O O O�: O O O as O oo w N Cl O Z y (N tt^^ Ln y:I: C to L6Cl y Z C �0 O O O O O O O O O O y (11 C C c7 a y Obi �. to O W in ill ot ('04 to O O t„ v H �t y v_ DRAWING N0. 94093002 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P PINED JUL - 7 2006 TOWNU ANDOVER ELTHPARTM TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 36 Shannon Lane_ —North Andover_ Owner's Name: Bobby Lie Owner's Address: _36 Shannon Lane —North Andover, MA 01845 Date of Inspection: 6/30/2006_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: _6130/2006_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Shannon Lane— _ North Andover— Owner: _ Lie Date of Inspection: _6/30/2006 _ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Shannon Lane- - North Andover_ Owner: _Lie_ Date of Inspection: 6/30/2006_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Shannon Lane _ _ North Andover— Owner: _Lie_ Date of Inspection: _6/30/2006 _ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _ No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No Liquid depth in cesspool is less than 6" below invert or available volume is'/s day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS, cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 Shannon Lane _ _ North Andover _ Owner: _Lie_ Date of Inspection: _6/30/2006 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No _Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes_ — Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? _Yes_ _ Were as built plans of the system obtained and examined? _Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? _Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ —Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No _Yes_ — Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Shannon Lane_ _ North Andover_ Owner: _Lie _ Date of Inspection: _6/30/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4 Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 _600 _ Number of current residents: _2 Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): _No Laundry system inspected (yes or no): Seasonal use: (yes or no): No_ Water meter reading: Yes _ Sump pump (yes or no): No Last date of occupancy: — Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _____gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): — Water meter readings, if available: — Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped four years ago, owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: ,1500_ gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: Inspect tank & tees_ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): _ Approximate age of all components, date installed (if known) and source of information: -12 Years old, 10/3/1994, as built plan _ Were sewage odors detected when arriving at the site (yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Shannon Lane_ _ North Andover _ Owner: _Lie_ Date of Inspection: 6/30/2006 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _36" Materials of construction: _X_ cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" PVC thru floor, 3" PVC in house with no leaks visible SEPTIC TANKS: X Depth below grade: _24" _ Material of construction: _X concrete _ metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth —411 _ Distance from top of sludge to bottom of outlet tee or baffle: 23" _ Scum thickness: _611 _ Distance from top of scum to top of outlet tee or baffle:-8"— Distance affle_8"_Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: _Tape Measure _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc: Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of septic tank leaking in or out. GREASE TRAP: (locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Shannon Lane_ _ North Andover— Owner: _Lie_ Date of Inspection: _6/30/2006_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: _ gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOXS: _X_ Depth below grade _4"_ Depth of liquid level above outlet invert: 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):_ D -Boz 1 is used as drop box. Vent is out of this bog. No carryover. No leakage. D -Box 2 is level & distribution equal. No carryover. No leakage._ PUMP CHAMBER: X (locate on site plan) Pump in working order (yes or no): Yes Alarm in working order (yes or no): Yes_ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber ok. Pump cycled on then off. Alarm has both audible & visual Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Shannon Lane _ North Andover - Owner: _Lie_ Date of Inspection: _6/30/2006_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. House A Water Meter —► C B Driveway Septic Tank Pump Tank D Box D -Box #2 #1 A to D -Box 1=108'3" A to D -Box 2 =105' 10" B to D -Box 1= 8214" B to D -Box 2 = 82'2" B to Septic Tank = 46'4" B to Pump Tank = 48'5" C to Septic Tank = 27'10" C to Pump Tank = 36'10" Vent Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Shannon Lane _ _ North Andover— Owner: _Lie_ Date of Inspection: _6/30/2006_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 4' _ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _2/9/1990_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: _ You must describe how you established the high ground water elevation: As per design plan_ Summary Record Card generated on 6/27/2006 9:50:57 AM by Elaine Barclay Town of North Andover Tax Map # 210-107.A-0228-0000.0 36 SHANNON LANE LIE, BOBBY 36 SHANNON LN NO. ANDOVER, MA 01845 Class 101 Single Family Size Total 1.28 Acres FY 2006 UB Mailing Index Name/Address Type Loan Number LIE, BOBBY Payor 36 SHANNON LN NO. ANDOVER, MA 01845 UB Account Maint. Property Type Active/inact. From Account No Cycle Occupant Name Bldg Id. 14223.0 - 36 SHANNON LANE Last Billing Date 6/13/2006 2100219 02 Cycle 02 UB Services Maint. METE METE w Water Service Code Posted Date Rate MISCFEE ADMIN FEE 15 0.635/8 WTR WATER 12/14/2005 01 ALL METER SIZE UB Meter Maintenance 13 6/8/2005 Serial No Status 3/15/2005 Location 39977015 a Active 20 ENC F.L. Date Reading Code 5/4/2006 854 m Manual estimate MSG 2/2/2006 834 m Manual estimate MSG 11/3/2005 819 a Actual Trouble Code: 13 8/10/2005 805 a Actual Trouble Code: 13 5/11/2005 795 a Actual Trouble Code: 13 2/14/2005 782 a Actual Trouble Code: 13 11/16/2004 766 a Actual Trouble Code: 13 8/11/2004 754 a Actual Trouble Code:09 5/17/2004 734 a Actual Trouble Code: 13 2/17/2004 729 a Actual 11/6/2003 710 n New Meter Active/Inactive Active Charge Multiplier/Users 7.82 1/ 67.80 /1 Brand Type METE METE w Water Consumption Posted Date 20 6/20/2006 15 3/13/2006 14 12/14/2005 10 9/12/2005, 13 6/8/2005 16 3/15/2005 12 12/17/2004 20 9/20/2004 5 6/14/2004 19 4/16/2004 0 11/6/2003 Size 0.63 0.63 Page t 1 Residential Until YTD Cons 0 Variance 33% 0% 50% -27% -15% 44% -47% 319% -70% 0% 0% Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use thepretum key. arra DEP has provided this form for use by local Boards -of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information 1. Sym Locatio : I LAI ec% Address I !?:�G City/Town 2._ System Owner: Name Address (if different from location) City/Town .B. Rumpi"g Record Zip Code Stat�...f Zip�,Qde TeIeeppho''neNeJNnml ber 1. .Date. of Pumping P g Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) 0--Sptic Tank ❑ Other (describe): 4: Effluent Tee Filter present? ❑ Yes L`t<0 5. Condition of System, 6. Syst-m Purred By :Name Company "— -7. 1_oCahefe contents we Sposed:. -;j — —Ruivi http://www.mass.90`V(dePtWater/approvals/t5forms.h"nspect Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 36 Shannon Lane, North Andover Owner: Lie Date of Inspection: 6/30 /2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. Form No. 3 Town of North Andover, Massachusetts BOARD OF HEALTH NORTH 1 9 pf tt�au ;eNp O joisilift9 DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSES Applicant ADpR SS TELEPHONE NAME 1' '�L ,� �1 � �v Gln ✓�-� L��� 'l!� n^ j. r Site Location �° I Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. e, :Y i3O- CHAIRMAN, BOARD OF HEALTH e� D.W.C. No.— Fee '� ' CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 5921 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508) 373-0310 FAX: (508) 372-3960 September 24, 1993 North Andover Board of Health Town Hall FIVE 120 Main Street North Andover, MA 01845 RE: "Lot 3, Shannon Lane Subsurface Disposal System Design Dear Board Members: On beha? f of by client, David 7a1 nq,?. of Cocli d.e Const::-uctiun, I would like to appear before the Board to discuss the recently submitted Revised Subsurface Disposal System Design for Lot 3, Shannon Lane. The design has been disapproved by Health Agent Sandy Starr for several reason, all but one of which may be resolved through minor design changes The remainding reason for disapproval is the fact the test pits on the lot are not current. According to Section 4.06 of North Andover's Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, "The results of the deep observation holes shall expire two years from the date conducted. Results upon which a subsurface sewage disposal system have been approved by the Board of Health shall be exempt from expiration." While it is true that over two years have passed since the tests were conducted, it is also true that an approval of a subsurface disposal system has been previously granted by the Board of Health. On February 20, 1990, the Board of Health issued Disposal Works Construction Permit No. 342 to Coolidge Construction for Lot 3 Shannon Lane. (A copy of the permit is attached.) Since Coolidge Construction desires to build on Lot 3 as soon as possible, it seems unfair that they sh,D Ild J+u a. until ne?ai. sptiiig to re -test the lot When the existing test results are valid under state regulations and meet the requirement for exemption from the more stringent local regulation. I look forward to meeting with you to resolve this issue at the next available meeting date. Please call me to notify me when you put us on the meeting agenda. Also, please call if you have any questions regarding this matjor. Ve do; lc IP ris sen cc: D. Zaloga DATE_ JQ/ y Sheet ` of BOARD OF HEALTH TOWN OF NORTH ANDOVER // SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # to 10,7 DATE RECEIVED g/9J APPLICANT l AV& 24zz G,,q ASSESSOR'S MAP ADDRESS ENGINEER H2/ 5 T/A, ,1 j;g1 J PARCEL # LOT # STREET ADDRESS Sv/1117&1Q 57- /4%gilee14jLG PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED y /. TESTS Na 7-c- &,e eewl- 9�9-` ��3 /iV�t�F�•ci�rriT(�1/, A. a /4 64)) e>f�GL 4 . �ES��' I/G ��PEi9 /1/o r �' �/�o�r �/�ir�,��y (/�/. /�. a� • � 3 . Gel NO T /' 'u�GpcJ �/ U/�P INLET_ f NORTHPw 1 a • r� sACMUSE'� Appli Town of North Andover, Massachusetts Form No's BOARD OF HEALTH _19 q3 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Site Location (.0"T -- Test No. Reference Plans and Specs. (2# 571-AN64W ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIRMAN, BOARD OF HEALTH Site System Permit No. bd-)— DATE 3LLZ- BO ARD OF HEALTH Sheet I of 1 i TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW _FEE C3 PERMIT # DATE RECEIVED s APPLICANT �� ��s� ASSESSOR'S MAP ADDRESS PARCEL # LOT # ENGINEER tg���e�� ` STREET 'g N�pN L,hj ADDRESS 160 SV Wig�1,' 1 c -r . I( PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED X tepr%4, "'tJt+�11L.. t 7)Vljp 41� b►g5�`� ��� w� t� "�� o �1,�.�lat1 s '�ti ouet cC- mrjtf, e og6g.S is kr LEA-5zir 6oc< r avta" 'n T ail 4-441ceps tres s 3� at, '�'iFt St�U+� � .1 gi- .11 lad' G „ tr—1 C ' 4Zx -V AD '34, t CSN 0WC0 6QVAL . ,pt`s L&VA to .b. vq t'1. t2 � s r w�t1s �o -46 p E CA IN's -rte ,ti std t -c t � SC- 14P6 Z* Weld$ tt V *aAV4 'm -IW-0 MONOr.lii�lte. ('vwc-n'c wAi �6.20 S CMt �a �t 9 `QsT' 6m-vuaa 1t � �+ off. - ltS ��c.�+ • -+.1 �o�o 90.0 -Ma► AScE C�^'.��+T ar►n s1�x4106 leC�ra .at .A tb! nom.. ♦'.n ...-p �1 . BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext. 32 or 52 February 20, 1992 Mr. Dave Zaloga Coolidge Construction Co., Inc. 401 Andover Street North Andover, MA 01845 RE: Lot #3 Shannon Lane Dear Dave: Please be advised that the plans for Lot #3 Shannon Lane have expired and cannot be extended without a variance being granted by the Board of Health. A request for variance should include the specific section of the regulation for which relief is being sought, the reason therefore, and the means by which the same degree of environmental protection will be achieved. The Board of Health is of the opinion that revisions to it's regulations should be incorporated in all plans which have expired. If revised plans cannot comply with the new regulations then relief should be sought through the variance process from the provisions which cannot be met. Previous requests for this type of variance have not been granted and I cannot recommend to the Board that such a variance be granted. Therefore, I recommend that the plan be revised to meet the new regulations and be resubmitted to this office for review. However, if you would like to apply for a variance, please forward such a request and I will place you on the next available agenda. Health Agent MJR/cjp azi cc: Karen H.P. Nelson, Director, Planning & Comm. Dev. COOLIDGE CONSTRUCTION CO., INC. 401 ANDOVER STREET NORTH ANDOVER, MASSACHUSETTS 01845 (617) 687-0109 N011T1/ f r �► b�Arao„� I 1JsACMUStt S Town of North Andover, Massa BOARD OF HEALTH iusetts Form No. 2 2-20 .1920 DESIGN APPROVAL FOR L ABSORPTION SEWAGE DISPOSAL SYSTEM Test No Applicant I Site Location '� 3 ,✓,t�Oti% G/� I?�\/15E-P rz�2—� Reference Plans and Specs. S�l�uS�,c� H�FR DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with 'regulations of Board of Health. E I HAI RMAN, B HEALTH d Fee � �y Site System Permit No. 2 Town of North Andover, Massachusetts Form No. a ,JR BOARD OF HEALTH Tp o K 1 X �'►''°•,o��''`�� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSEt Applicant LL`L �✓T NAME ADDRESS TELEPHONE Site Location 0 Permission is hereby granted to Construct ft or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 3y% e i Fee ' :OU Al -At; ,r AIRMAN, ARD OF HEALTH 'i D.W.C. No. BOARD OF HEALI H ���6 '�� ���� .. �.�� ,.!.. �:'; :; .::. ,'r:.:: ,: , '� . �r, Z, d LZ ondY/7 i-�-, � fcA a v� vl0LQ-V\. sw U (,-j f ,ley eve t2/ e� l� - �,jk C �5�� F-IURD of H - Nol�TN /jtiI�OVE�� � NIA, SS34 — 4"m)ev D15APPROV�p R�OSaNS W, SO PPL7 Wnl D WEU--APftUED 5EI fI c GY STEM L SA < 1 DAr6' -2- �I'i�vw� �u�r�o►��ry G U,a 2 Co�otr�a�5 94-16 D Irl '5 Prc 6 S"6TEM P J S VA LLATlOA-) j5-X4V4T(c►,A,J JNSPt�-.c ► IoAJ 9/1 rG Eig5S CJ r4►L_ I ti5PE:�:rlonj' PIPE FROA-\ t-JvO'5t- F() TMJ nJ Pry S5 t=SIL pPPi�dvEP G)/3TC API il�OJw6 AUTHof�i y &DITj0 AL, I A)Ybc toNS X j ,oYjy ) DISAPMO\JFI7 R�,So tvs FVAL APPIZ VAL Arc4. APPi�wv,-'6 16u ainj I F\/ �Notice to APPLICANT/TOWN CLEMX and Cortification of Action of PlaiZgr., Board on Definitive Subdivision Plan ontitlod: SHANNON LANE i By: Christiansen Engineerinct, Inc. dated April 26S4 S4 ` The North Andover Planning Board has voted to APPROVE said plan, subject to the following conditions: 1. That the record owners of the subject land forthwith execute and record = a "covenant mming vith the land", or otherwise provide security for the con—,.. st.ruction of ways and the installation of municipal. services Athin said sub— division, all as provided by G.L. c. Zat S. 81-U. 2. That all such construction and installations shall in all respects conform to.tho governing rules and regulations of this Board. Any changes to the ------ approved polan by the developer, town board, or agancy shall be $ubmitted to,thi Planning ghatf ° asapr�'qu°ir®fid b t�Tieei�' '' l'A�i eIp%?Sd � RW �g.R�L� �p6�: �,. fief this Board, no building or other structure'ohall be buUt•or placed upon Lots leo. 1 through 5 as shorn on said Plan without the prior consent of said Board of Health. 4. Other conditions: a. All Planning Board order of conditions are to be placed on the recorded definitive plan.(b) Prior to signing the definitive plans all deeds of easements shall be submitted to the Planning Board and held in escrow until completion. At the time of completion the developer:or owner shall execute such documents for the Town. (c) A certified as -built plan shall be submitted showing the location of all utilities(electric; water, sewer, telephone) prior to binder coat application. (d) Final as -built plans shall be submitted to the Planning Board prior to final release of security. W,`A. certifies? plan from"a Registered Engineer or.Land Surveyor shall be submitted'. to the Planning Board for review detailing proposed stump pit areas for approv, prior to construction. All stump pit areas are to be approved by the Highway Surveyor. (f) The applicant/owner/developer-.shall be aware of the fact that Aff"Oval of this subdivision under the Planning Board's Rules & Regulations not relieve said parties of the responsibility to other property owners whose land may be affected by indirect or direct development storm water. arge Yn the event that no appeal shall have been taken from said approval w:i.thin twent,y days from this date, the North Andover P1amLi.ng Board ..rill forthwith thoreafter endorse its formal approval upon said plan. M M FORTH MOVER PWINTING BOARD raj,^. July 1, 1985 By: Michael P. Roberts DEFINITIVE PLAN OF LAND SHANNON LANE CONDITIONAL APPROVAL JULY 1, 1985 5. A Notice of Intent shall be filed with the NorthAndover Conser- vation Commission as required under Ch. 131, Wetlands Protection Act and local Conservation Commission's regulations and any changes required may be cause for reconsideration of the subdivision under M. G. L., Ch. 41. 6. In accordance with the Fire Departments recommendations: a. In order to provide water for fire protection as indicated in Section VF Water Facilities of the subdivision control '> -- --- regulations, a hydrant shall be installed 500 feet from the hydrant at Summer and Farnum'Streets on Farnum Street.. b. All numbers shall be posted during construction; C. Permanent house numbers shall be posted on dwellings prior to occupancy; d. No open burning is to be permitted except during open burning 'season under fire department regulations; e. All builders must comply with the.fire departments underground fuel storage regulations; f. Prior to taking occupancy, the subdivision streets shall provide adequate access to each residence for fire apparatus. L 7. In accordance with the Highway Surveyor: a. Catch basin frames and grates shall be four flange with, checker board type grates. 8. All requirements of the Subdivision Control Laws pertaining to 'Street Trees' shall be enforced by'the Tree Department. 9. No roadway construction shall take place until detail cross- ---------- sectional plans have been submitted to the Planning Board showing how the applicant plans to fill the area between land owned by Powell and Levitt. 10. In order to ensure that 100 year storm waters get into the proposed detention pond, the end of the cul-de-sac shall be sloped upward in the vicinity of Lots 2 a-nd 3. This condition will prohibit drainage fromflowing to lots 2 and 3 and direct it to the pond. 11. Roadway cross section shall be in conformance with the Planning Board's Rules and Regulations 12. In accordance with the Public Works recommendations: a. The water main on Shannon Lane shall be 8" class 52 ductile iron cement lined water pipe installed 10 feet left of the centerline of the road with 5 feet of cover below the finish grade from the.existing water main in-Farnum Street to Station 5+20. M — - -- -DEFINITIVE PLAN OF LAND SHANNON LANE CONDITIONAL APPROVAL JULY 1, 1985 b. An 8" x 8" tapping ' pp g sleeve and gate valve(open left) shall be provided at the existing water main in Farnum Street. C. Eddy Break flange hydrants to North Andover specifications are to be installed at station 0+0 and 5+20; d. All hydrant branches'shall be provided with six inch Mueller or equal gate valves (open Left). e. All gate valves shall comply with AWWA specifications L500 52T amd will be supplied with a. 100 lb. sliding type gate box marked "WATER". f. All water mains shall pass leakage and pressure test performed in accordance with section'13 of.the AWWA standard C600 and shall be chlorinated in accordance with AWWA C601 "Standard Procedure for Disinfecting Water Mains." PLAN REVIEW CHECKLIST ADDRESS 1,/)7-,-3 3#AAX AI 1-1,4 ENGINEER (2111?157-/MISE-z l GENERAL 3 COPIES STAMP C� LOCUS NORTH ARROW_ SCALE_ tip' T x) CONTOURS l/� PROFILE SECTION l/' BENCHMARK iW.. P�O'SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER `� WELLS & WETLANDS FDN DRAIN V SEPTIC TANK MIN 1500G. WATERSHED? DRIVEWAY (Elev) WATER LINE SCH40 K TESTS CURRENT? Y6 25' TO CELLAR D -BOX SIZE :P,6- .17 INVERT DROP MANHOLE TO GRADE INLET Dom/ , d - OUTLETo��� �%� ao/ go a01.024 LEACHING GARB. GRINDERA/0 (+200% EDF) ELEV GW 3a # LINES 3 FIRST 2' LEVEL STATEMENT '/6 (2" OR .17 FT) TEE REQ'D?/Vd /6 RESERVE AREA (/4' FROM PRIMARY? 100' TO WETLANDS &"""' 2% SLOPE 100' TO WELLS 35' TO FND & INTRCPTR DRAINS ✓ 4' TO S.H.GWL---- 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY !� MIN 12" COVER t-- ' FILL?� (25' if above natural elev; 101if below) BREAKOUT MET? "' TRENCHES (� �/ TO . P6p 016 V� MIN 660 gpd SLOPE (min .005 or 6"/1001) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61)•✓ IS RESERVE BETWEEN TRENCHES? C/ IN FILL?_jZ MUST BE 10' MIN. 4" PEA STONE? BOT �8�X LDNGs3'`v� SIDE - X LDNG a = (L x W x #) (G/ft2 ) (Dxi, TOT x#) /giz 64� ,)4� PITS MIN 660 LEACHING EXCAV 2x EFF W OR D GW MIN 4' BELOW BOTTOM 12"-48" STONE SURROUNDING BOT + SIDE x LOAD (L x W x #) (2 x (L+W) x D x #) CHAMBERS COVER >3 FT - VENT FIELDS MANHOLE/PIT = TOTAL MIN 900 ft2 LEACHING PERC RATE FASTER THAN 20M/IN GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE? 4" PEA STONE? DIST LINE SLOPE .005? >3' COVER - VENT SCH 40 MIN 12" COVER L x W = T x LDNG > DESIGN FLOW? DOSING TANKS AND PUMPS DIMENSIONS; -6 , XS 9 X<-�D = 1069 G PUMP CAPACITY P f40N gpm L W W Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME MANHOLES TO GRADE 4---' ALARM ALARM SEP. CIRC. GW_A- (Min. 1' below inlet) HWL/ 7 7, 7j LWL/&. 9 CHECK VALVE f/ BLEEDER HOLE MANUAL OP. SWITCH —,eE�Z A/L G r FORM U -LOT RELEASE FORM INSTRUCTIONS: This form is used to ve-- fy that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ( C co +. Phone (i� % LOCATION: Assessor's Map Number -/02_4 Parcel Subdivision r Lot(s) Street St. Number ************************Official use only************************ REC0MH DATIONS OF TOWN AGE iTS : Data Conservation Administrator Date Rejected Comments � aLLM. T wn Planne_' �/� Comments J.t'� 0 P (� An 0� Date Approved Dates Rej ec ted _ Data Approved Health Aaent Date Rejected Comments Public Warks _7-ewe-/Iwater connection - drivewav permit Fire Department Received by Building Inspector Data it -11, al t I 7, M17, I � p I, AL -� (n � i i �, I it -11, al t I 7, M17, I 4 ! y ri 4 F Fi g 4 - tg"RAI i FFF � r 00 s I i I i I I I I , ; � i i I I I I 00 s I i I i I I I I , ; � i i I I I • � G r, J J � 1 � 3 ACTION -KING ENTERPRISES, INC. 26 LIVINGSTON STREET LOWELL, MA 01852 TEL: (508) 452-7750 FAX: (508) 459-0770 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:36 SHANNON LANE, NOR. ANDOVER, MA 01845 DATE OF INSPECTION: 4-15-96 ADDRESS OF OWNER: NAME OF INSPECTOR: FRANCIS KING III (IF DIFFERENT) CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS TRUE, ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS. THE SYSTEM. X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTION REPORT TO THE APPROVING AUTHORITY WITHIN THIRTY (30) DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GPD OR GREATER, THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION. THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER, IF APPLICABLE AND THE APPROVING AUTHORITY. INSPECTION SUMMARY: CHECK A, B, C, OR D. A) SYSTEM PASSES: X I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM VIOLATES ANY OF THE FAILURE CRITERIA AS DEFINED IN 310 CMR 15303. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. B) SYSTEM CONDITIONALLY PASSES: ONE OR MORE SYSTEM COMPONENTS NEED TO BE REPLACED OR REPAIRED. THE SYSTEM UPON COMPLETION OF THE REPLACEMENT OR REPAIR, PASSES INSPECTION. INDICATE YES, OR NO, OR NOT DETERMINED (Y, n, OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL INSTANCES. IF "NOT DETERMINED EXPLAIN WHY NOT. THE SEPTIC TANK IS METAL, CRACKED, STRUCTURALLY UNSOUND, SHOWS SUBSTANTIAL INFILTRATION OR EXFILTRATION, OR TANK FAILURE IS IMMINENT. THE SYSTEM WILL PASS INSPECTION IF THE EXISTING SEPTIC TANK IS REPLACED WITH A CONFORMING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH. PAGE 1 ACTION -KING ENTERPRISES, INC. 26 LIVINGSTON STREET LOWELL, MA 01852 TEL: (508) 452-7750 FAX: (508) 459-0770 PROPERTY ADDRESS: 36 SHANNON LANE NO. ANDOVER, MA 01845 OWNER: THOMAS MOSER DATE OF INSPECTION: 4-0-96 ACTION KING ENTERPRISES, INC. HAS BEEN RETAINED BY THE OWNER TO PROVIDE AN INSPECTION OF THE ON-SITE SEWERAGE DISPOSAL SYSTEM AS DEFINED BY 310 CMR 15.303.D.E.P. GUIDANCE INSTRUCTS THE INSPECTOR TO MAKE AN EVALUATION OF THE SYSTEMS PERFORMANCE ON THE DAY OF THE INSPECTION. THE TITLE 5INSPECTION IS NOT DESIGNED TO PROVIDE INFORMATION TO DEMONSTRATE THAT THE SYSTEM WILL ADEQUATELY SERVE THE USE TO BE PLACED UPON IT BY THE NEW OWNER AS STATED IN 15302. THIS ISPECTION IS NOT A WARRANTEE OR GUARANTEE OF THE SYSTEM FUTURE PERFORMANCE, AND DOES NOT EITHER EXPRESS OR IMPLY IT. PAGE 1-A ACTION -KING ENTERPRISES. INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 36 SHANNON LANE NO. ANDOVER, MA 01845 OWNER: THOMAS MOSER DATE OF INSPECTION: 4-15-96 B) SYSTEM CONDITIONALLY PASSES (CONTINUED) NIA SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL OBSERVED IN THE DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPES) OR DUE TO A BROKEN, SETTLED OR UNEVEN DISTRIBUTION BOX. THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF THE BOARD OF HEALTH). BROKEN PIPE(S) ARE REPLACED OBSTRUCTION IS REMOVED DISTRIBUTION BOX IS LEVELED OR REPLACED THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF THE BOARD OF HEALTH). BROKEN PIPES) ARE REPLACED OBSTRUCTION IS REMOVED C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NIA CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A SURFACE WATER CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A BORDERING VEGETATED WETLAND OR A SALT MARSH. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IF FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN 100 FEET TO A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN A ZONE I OF A PUBLIC WATER SUPPLY WELL. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS LESS THAN 100 FEET BUT 50 FEET OR MORE FROM A PRIVATE WATER SUPPLY WELL, UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THE 5PPM. PAGE 2 ACTION -KING ENTERPRISES. INC. D) SYSTEM FAILS: NIA I HAVE DETERMINED THAT THE SYSTEM VIOLATES ONE OR MORE OF THE FOLLOWING FAILURE CRITERIA AS DEFINED IN 310 CMR 15303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTACTED TO DETERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILUR. 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 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 V2 DAY FLOW. REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED ANY PORTION OF THE SOIL ABSORPTION SYSTEM, CESSPOOL OR PRIVY IS BELOW THE HIGH GROUNDWATER ELEVATION. ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. IF THE WELL HAS BEEN ANALYZED TO BE ACCEPTABLE, ATTACH COPY OF WELL WATER ANALYSIS FOR COLIFORM BACTERIA, VOLATILE ORGANIC COMPOUNDS, AMMONIA NITROGEN AND NITRATE NITROGEN. E) LARGE SYSTEM FAILS: THE FOLLOWING CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITERIA ABOVE. NIA THE DESIGN FLOW OF SYSTEM IS 10,000 GPD OR GREATER (LARGE SYSTEM) AND THE SYSTEM IS A SIGNIFICANT THREAT TO PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT BECAUSE ONE OR MORE OF THE FOLLOWING CONDITIONS EXIST: THE SYSTEM IS WITHIN 400 FEET OF A SURFACE DRINKING WATER SUPPLY THE SYSTEM IS WITHIN 200 FEET OF A TRIBUTARY TO A SURFACE DRINKING WATER SUPPLY. THE SYSTEM IS LOCATED IN A NITROGEN SENSITIVE AREA (INTERIM WELLHEAD PROTECTION AREA (WPA) OR A MAPPED ZONE II OF A PUBLIC WATER SUPPLY WELL. THE OWNER OR OPERATOR OF ANY SUCHSYSTEM SHALL BRING THE SYSTEM AND FACILITY INTO FULL COMPLIANCE WITH THE GROUNDWATER TREATMENT PROGRAM REQUIREMENTS OF 314 CMR 5.00 AND 6.00. PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FOR FURTHER INFORMATION. PAGE 3 ACTION -KING ENTERPRISES, INC. PART B CHECKLIST PROPERTY ADDRESS: 36 SHANNON LANE NO. ANDOVER, MA 01845 OWNER: THOMAS MOSER DATE OF INSPECTION: 4-15-96 CHECK IF THE FOLLOWING HAVE BEEN DONE. X PUMPING INFORMATION WAS REQUESTED OF THE OWNER, OCCUPANT, AND BOARD OF HEALTH. X NONE OF THE SYSTEM COMPONENTS HHAVE 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. X AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. _ X THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. _ X THE SYSTEM DOES NOT RECEIVE NON -SANITARY OR INDUSTRIAL WASTE FLOW. _ X _THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. X ALL SYSTEM COMPONENTS, EXCLUDING THE SOIL ABSORPTION SYSTEM, HAVE BEEN LOCATED ON THE SITE. X THE SEPTIC TANK MANHOLES WERE UNCOVERED, OPENED, AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEE, MATERIAL OF CONSTRUCTION, DIMENSIONS, DEPTH OF LIQUID, DEPTH OF SLUDGE, DEPRTH OF SCUM. X THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROZIMATED BY NON -INTRUSIVE METHODS. _X THE FACILITY OWNER AND OCCUPANTS, IF DIFFERENT FROM OWNERS WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUB -SURFACE DISPOSAL SYSTEM. PAGE 4 ACTION -KING ENTERPRISES, INC. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION PROPERTY ADDRESS: 36 SHANNON LANE NO. ANDOVER, MA 01845 OWNER: THOMAS MOSER DATE OF INSPECTION: 4-15-% RESIDENTIAL: DESIGN FLOW: 440 GALLONS. NUMBER OF BEDROOMS: 4 NUMBER OF CURRENT RESIDENTS: 4 GARBAGE GRINDER (YES OR NO) NO SEASONAL USE (YES OR NO) NO WATER METER READINGS, IF AVAILABLE: N/A LAST DATE OF OCCUPANCY: OCCUPIED COMMERCIAL/INDUSTRIAL: TYPE OF ESTABLISHMENT: N/A DESIGN FLOW: GALLONSIDAY GREASE TRAP PRESENT, (YES OR NO) INDUSTRIAL WASTE HOLDING TANK PRESENT: (YES OR NO) NON -SANITARY WASTE DISCHARGED TO THE TITLE 5 SYSTEM: (YES OR NO) WATER METER READINGS, IF AVAILABLE: LAST DAY OF OCCUPANCY: OTHER: (DESCRIBE) LAST DAY OF OCCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION. 11 MONTHS OLD SYSTEM PUMPED AS PART OF INSPECTION (YES OR NO) YES IF YES, VOLUME PUMPED 1560 GALLONS. REASON FOR PUMPING INSPECTION TYPE OF SYSTEM X SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM _ - SINGLE CESSPOOL OVERFLOW CESSPOOL PRIVY SHARED SYSTEM (YES OR NO) (IF YES, ATTACH PRVIOUS INSPECTION RECORDS, IF ANY) X OTHER (EXPLAIN) SEPTIC TANK WITH PUMP CHAMBER TO D - BOX TO 4 LEACH TRENCHES. APPROXIMATE AGE OF ALL COMPONENTS, DATE, INSTALLED (IF KNOWN) AND SOURCE OF INFORMATION. 11 MONTHS (HOME OWNER) SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE. (YES OR NO) NO. PAGE 5 A rTTnN-KMr FNTFRPRTCFQ9 TNC. PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 36 SHANNON LANE NO. ANDOVER, MA 01845 OWNER: THOMAS MOSER DATE OF INSPECTION: 4-15-96 SEPTIC TANK: X (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: ONE FOOT MATERIAL OF CONSTRUCTION: X CONCRETE METAL FRP OTHER (EXPLAIN) DIMENSIONS: 8'X 6'X 5' SLUDGE DEPTH: 1' DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 2' SCUM THICKNESS: 0 DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 4" DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: (0) NO SCUM COMMENTS: (RECOMMENDATION FOR PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, DEPTH OF LIQUID LEVEL IN RELATION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE, ETC.) TANK CONDITION LOOKED GOOD - OUTLET AND INLET BAFFLES IN PLACE. GREASE TRAP: NIA (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: MATERIAL OF CONSTRUCTION: CONCRETE METAL FRP OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: COMMENTS: (RECOMMENDATION FOR PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, DEPTH OF LIQUID LEVEL IN RELATION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE. ETC.) PAGE 6 ACTION -KING ENTERPRISES, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 36 SHANNON LANE OWNER: THOMAS MOSER DATE OF INSPECTION: 415-96 TIGHT OR HOLDING TANK: NIA (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: MATERIAL OF CONSTRUCTION: CONCRETE METAL FRP OTHER (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: GALLONS/DAY ALARM LEVEL COMMENT: (CONDITION OF INLET TEE, CONDITION OF ALARM AND FLOAT SWITCHES, ETC.) DISTRIBUTION BOX: X (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0 COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL, EVIDENCE OF SOLIDS CARRY OVER, EVIDENCE OF LEAKAGE INTO OR OUT OF BOX, ETC.) D - BOX LOOKED GOOD - TWO D- BOX SYSTEM - ONLY LOOKED AT #1 COULD NOT LOCATE #2 - LEVEL IN #1 HAD NO SIGNS OF SOLIDS CARRYING OVER TO FIELD. PUMP CHAMBER: (LOCATE ON SITE PLAN) PUMPS IN WORKING ORDER (YES OR NO) YES COMMENTS: (NOTE CONDITION OF PUMP CHAMBER, CONDITION OF PUMPS AND APPURTENANCES, ETC.) PUMPS ARE IN WORKING ORDER - NO SIGNS OF PREVIOUS PROBLEMS PAGE 7 ACTION -KING ENTERPRISES, INC. PROPERTY ADDRESS: 36 SHANNON LANE NO. ANDOVER, MA 01845 DATE OF INSPECTION: 4-15-96 SOIL ABSORPTION SYSTEM (SAS). X (LOCATE ON SITE PLAN, IF POSSIBLE, EXCAVATION NOT REQUIRED, BUT MAY BE APPROXIMATED BY NON-INTURSIVE METHODS). IF NOT DETERMINED TO BE PRESENT, EXPLAIN: TYPE: LEACHING PITS, NUMBER: LEACHING CHAMBER, NUMBER: LEACHING GALLERIES, NUMBER: LEACHING TRENCHES, NUMBER LENGTH: (3) TRENCHES 41W X 50' L LEACHING FIELDS, NUMBER, DIMENSIONS: OVERFLOW CESSPOOL. NUMBER: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION OF VEGETATION, ETC.) AREA WHERE LEACH TRENCHES ARE LOCATED APPEAR TO HAVE NORMAL SURROUNDING CESSPOOLS: N/A (LOCATE ON SITE PLAN) NUMBER AND CONFIGURATION: DEPTH -TOP OF LIQUID TO INLET INVERT: DEPTH OF SOLIDS LAYER: DEPTH OF SCUM LAYER: DIMENSIONS OF CESSPOOL: MATERIALS OF CONSTRUCTION: INDICATION OF GROUNDWATER: INFLOW (CESSPOOL MUST BE PUMPED AS PART OF INSPECTION: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULICA FAILURE, LEVEL OF PONDING, CONDITION OF VEGETATION, ETC.) PRIVY• N/A (LOCATE ON SITE PLAN) MATERIALS OF CONSTRUCTION: DIMENSIONS: DEPTH OF SOLIDS: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION OF VEGETATION, ETC.), PAGE 8 ACTION -KING ENTERPRISES, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 36 SHANNON LANE NO. ANDOVER, MA 01845 OWNER: THOMAS MOSER DATE OF INSPECTION: 4-15-96 SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR BENCHMARKS COAT ALL WELLS WITHIN 100 SEE ATTACHED PLANS DEPTH TO GROUNDWATER DEPTH TO GROUNDWATER: >12 METHOD OF DETERMINATION OR APPROXIMATION:_ SMALL POND APPROXIMATELY 500 FEET AWAY. 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HAVERHILL.MA. 01850 TEL 508-375-0310 © 1994 BY CHRISTIANSEN & SERGI INC. I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, ORDERS OF CONDITIONS,ETCJ 7I115 DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. DWG. NO.:94093001 37.40' 1 Z TOP FND. ®BACK SEL. =193.1 ' J� N 40.94' 1 222.84' - FOUNDATION LOCATION PLAN CLIENT. COOLIDGEE CONSTRUCTION THIS CERTIFICATION /S MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: LOT 3 ^- SHANNON LN.,NO.ANDOVER SCALE: 1"=60' DATE: 9/8/94 REV.: 9/17/94 PRO CHRISTIANSEN ,\SERGI LAND SURVEYORS ENGINEERS SURVEYO S 160 SUMMER ST. HAVERHILL.MA. 01850 TEL 508-375-0310 © 1994 BY CHRISTIANSEN & SERGI INC. I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, ORDERS OF CONDITIONS,ETCJ 7I115 DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. DWG. NO.:94093001