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Miscellaneous - 37 ANNE ROAD 4/30/2018 (2)
.i' .�`�,." 0 01 Lot & Street er Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: CYES Plan Approval: Date: J Designer:fI12r ��, 1iu r��h Conditions: Water Supply: Town Well Well Permit: Well Tests: Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: Driller: NO Permit# //4 -1 - Approved by: Plan Date: Date Approved Date Approved Date Approved Wiring,Sign-off: Form "U" Approval: Approval to Issue Date Issued By:_ Conditions: Final Approval: YES NO All Permits Paid? ES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? GE NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: CONDITIONS: Is the installer licensed? Type of Construction: New Construction: Issuance of DWC permit: DWC Permit Paid? DWC Permit # Begin Inspection: Excavation Inspection: Needed: SEPTIC SYSTEM INSTALLATION YE NO NEW EPA Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U NO Passed: // A, /, / By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: Final Grading Approval: Date N� U\L— — Aa 6 'v V . r 0 e�> � � � k f NO NO Installer: Installer: -) 0 .,YES NO Final Construction Approval: Date:. (l' fl I By:�_ Certificate of Compliance: Approval: Date: I 7J Z b' MAP # 376 LOT # ............ PARCEL # STREET 4.10..._._.--.__...._...._____....._ CONSTRUCTION APPROVAL .. . ....... . .. ......... SA HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE APP. DESIGNER: PLAN DATE. --- CONDITIONS_ e0oc-" WATER SUPPLY: OWN WELL WELL PERMIT DRILLE WELL TESTS: CHEMICAL BACTERIA I COMMENTS: BACTERIA II DATE APPROVED DATE APPROVED DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSUE ES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: av� NO i PES NO E NO YES `N 0 DATE: )-_] .. �A q olloel--il_y .. .......BY: I IS THE INSTALLER LICENSED?ES NO TYPE OF CONSTRUCTION: NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES qk);i t -lea -o t>� SE -r (ki 44tA OF FieLp I wj- -ral v- DWC PERMIT NO.. -Z— INSTALLER: ..... .......... . .. .. BEGIN INSPECTION (:iiio: EXCAVATION INSPECTION: NEEDED:------ ...... ...... .......... ..... . ....... ... --.- . ...... PASSED 17 CONSTRUCTION INSPECTION: NEEDED: A AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: FINAL GRADING APPROVAL: DATE_BY._..__...,_.. �`�t� FINAL CONSTRUCTION APPROVAL: DATE: ------- ...... .... . SO Expires Name Association Town State 3920 6/30/2016 Darren M. Meyer East Sandwich MA 12899 6/30/2017 Timothy Meyers North Easton MA 2430 6/30/2016 Edward Michael, Jr. E.M. Construction Co. Fall River MA 3595 6/30/2016 Darren J. Michaelis West Wareham MA 9970 6/30/2017 Christopher Michaud Westport MA 258 6/30/2016 David J. Michniewicz Coastal Engineering Co., Inc. Orleans MA 2720 6/30/2016 Raymond Mieczkowski Hadley MA 733 6/30/2016 Edmond W. Miga Palmer NIA 283 6/30/2016 Brian F. Milisci Whitman & Bingham Assoc., Inc. Leominster MA 13748 5/1/2017 Marcus Millett Homestead Inc. Ashfield MA 4371 6/30/2016 Randy Miron Bohler Engineering, PC Southborough MA 4417 6/30/2016 Erik Mitchell Wellfleet BOH Chatham MA 557 6/30/2016 Randy Mizereck Hubbardston MA 11305 6/30/2016 Michael G. Mocko, Jr. Stafford Springs CT 3457 6/30/2016 Scott A. Moles Taunton NIA 3722 6/30/2016 Todd Moline Rumford RI 558 6/30/2016 Donald W. Moncevicz West Dennis MA 3103 6/30/2016 Dean R. Monsees Riverside RI 560 6/30/2016 John J. Monteiro Allied Septic Service Inc. North Falmouth MA 13620 12/1/2015 Joseph Montoya A #1 Southport Hanover MA 1924 6/30/2016 John Moon Plymouth NIA 561 6/30/2016 James P. Mooney Attleboro MA 12869 6/30/2017 Kenneth Moore Timbers to Trim Construction Wales MA 2119 6/30/2016 David H. Moquin Howard D. Moquin & Sons Const. Middleborough MA 2152 6/30/2016 Gary T. Moquin HD Moquin and Sons Middleborough MA 725 6/30/2016 Brian V. Moran Town of Holliston Holliston MA 4555 6/30/2017 Mark J. Moran HDS Liquids, Inc. Carver MA 4045 6/30/2016 Michael B. Moreau, Jr. Mattaposiett MA 4329 6/30/2016 Jesse M. Moreno Granby MA 12907 10/1/2016 James Morin Belmont MA 2083 6/30/2016 Peter L. Moroni Moroni Bros. Inc. West Bridgewate MA 297 6/30/2016 John W. Morris Billerica MA 13473 6/30/2017 Joseph L. Morriseau Zephyrhills FL 13672 3/1/2016 Dianna Morrison Templeton Board of Health Baldwinville MA 4270 6/30/2016 Gregory J. Morse Morse Engineering Co., Inc. Scituate MA 564 6/30/2016 Richard G. Morse Dick Morse Excavating Sharon MA 13399 6/30/2016 Bruce Moschetti F.A. Moschetti & Sons Templeton MA 13400 6/30/2016 Franklin Moschetti F.A. Moschetti & Sons Templeton MA 12861 6/30/2017 Mark Moschetti F.A. Moschetti & Sons Templeton MA 756 6/30/2016 Christopher C. Mossman Trowbridge Engineering Westminster MA c=* 5018 6/30/2016 Anthony R. Mottolo John Zanni Pumping Co., LLC North Reading MA /�ia-'^•'t!� 47 13654 3/1/2016 Lara J. Mottolo Service Pumping & Drain North Reading MA 167 6/30/2016 Richard A. Mottolo Service Pumping & Drain Co., Inc. North Reading MA � � ' 1 3740 6/30/2016 Eric F. Mueller Southeast Septic Services Carver MA t) V1 13642 6/30/2016 Philip J. Muller Gloucester MA��4 2423 6/30/2016 Matthias J. Mulvey Weymouth MA nOJ� 3675 6/30/2016 Brian S. Murphy DBA B & D Septic Inspections Hull MA 1 13493 6/30/2018 Jeffrey R. Murphy Southborough MA 3889 6/30/2016 John B. Murphy Wilmington MA 569 6/30/2016 Kevin P. Murphy K. P. Murphy Excavating Middleborough MA 170 6/30/2016 Mark E. Murphy Wm. F. Murphy Inc. Stow MA 4451 6/30/2016 Paul Murphy East Falmouth MA 4760 6/30/2016 William Murphy Weston MA 2799 5/1/2017 Francis N. Murphy, Jr. Beland Septic South Grafton MA 171 6/30/2016 William F. Murphy, Jr. Wm. F. Murphy. Inc. Stow MA 2106 6/30/2016 William E. Murray PLACES Site Consultants, Inc. Hubbardston MA 570 6/30/2016 Brian M. Mushenko Monson MA 3858 6/30/2016 John Mustain J. Mustain Land Consultant East Otis MA Tuesday, August 11, 2015 Page 17 of 26 �AT W.- a rg m r. n m dY(o' -r4Iti rL. -j i 4 efvnCIGA'ra," IS ooT A TY O f 'N E i%J8'e7U94,w-9 lurotplL 4yd,TEH - TT 1+ A eL4o" OF r�-1E LaA-rbc! A uo E I•E vomoJ OF 'rW ac e-1 n Nes *Y' Vrq LOH f0 W lc►J Ty. . AS BUILT PLAN OF SUBSURFACE LOCATED IN a -.9v FT� ANpovfTP-- AS PREPARED FOR DoU� Pv�-r°r DATE: II�20-D� SCALE: T 0 O, DISPOSAL SYSTEM �� Pj 1c AVOS CIVIL No. 3775 2 5 + ,. MER RIMACK ENGINEERING SERVICES, INC.A LAM PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET 4 ANDOVER, MASSACHUSETTS 01810 6 TEL (617) 475-3533, 373-5721 Sc eT r (--. C-. t L.c S Z—.(_,.S . bA p EPT t G Et`,t��l. 1(22(4( SrcPrtG I C� l . 140. %fo ou-r o F Fl sem. Z. \ 40.4 S lLJTO -T-P%.3 K._ l ro ov-r o F TA+s 4c- 4. 1 sq•S3 Iwrro (5=K 5. 184.x3 our of R6ow ro. l84.6f �1 t34. Sg I uv. • 1134.45 I uv. = Grc-2-TI)=y THAT o F"FS�TS SHdw►_J A2..� �oT�. THE, �,�� '^ THE, a t= F S>cTs USE. o r -r -T-l4 U I t,_, p I 1.1 C-, i� A ....I D �c! tT4l THE. Q (KJGDIGTErg tiller ATlo1._{ dl= �otil ISG tea C,o k...I f=- C=. re- C• l jot�rF( �uoov��, \TY �1 HE. �1 Go ►�1 S� 2,t�GTE.Q. rEG`�' Z S o l 22(8 l Town of North Andover, Massachusetts Form No. 2 ' • "ORrM BOARD OF HEALTH c � s DESIGN APPROVAL FOR ass"`14U SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant�77 Test No. �C3lo� Site Location_ Reference Plans and Specs. ENGINEER DESIGN SCJ DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. _ CHAIRMAN, BOARD OF HEALTH Fee k Site System Permit No.—Z/ 1p Town of North Andover Office of the Health Department Community Development and Services Division V Charles Street. North Andover, Massachusetts 01845 Sandra Starr Public Health Director TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE Inspected on 12/28/01 This is to certify that the individual subsurface disposal system constructed Q or repaired (X) by John Shaki at 37 Anne Road Telephone (978) 688-9540 Fax (978) 688-9542 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. rian J. LaGrasse Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688 9530 HEALTH 688-9540 PLANNING 688-9535 q 3 D C L OCA. ION: OL", i ION S _ I D I ` .A N C,0 =. i ION i i .= ,Z/ r CI�IOItiI'J I,—C,-=-=r-- I OC iilvIE i E n TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (repaired: by _ �I f?�-i 0 located at _ Z7 A L A') ILQ¢ 0 was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # , dated , with an approved design flow of4-40 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bed inspection date: Engineer-Rep-rese tative Final inspection date:-//-R/--O/ e , .c, Engineer Representative Installer Lic.#: Date: 0 Design Engineer: joic.Date: ����� PAGE 1 OF 5 ig .,..,—Commonwealth of Massachusetts Application for i mal Upgrade Approval Title 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) To t)c submitted to Leal Approving ktftritv/Hoard of Health: For the upgrade of a failed or nonconforming system with a design flow of < 10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full compliance, as defined in 310 CMR 15.404(1), is' not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 tMR 15.000. 1) Facility/system owner Name L Aga* f U&16, L& ra ' Address Phone # '170 (aeq-'0414 Address of facility �7 sti u Y b 2) Applicant *(if different from above) Namer�'d— Address Phone # 3) Type of fMdential commercial e school institutional (Spey) aD!? AF'F'ROM FORM - UM7M! PAGE 2 OF S 4) Type of existing system _privy cesspools) conventional system Other (describe) Type of soil absorption system (trenches, chambers, pits,etc.) 5) Design flow based on 310 CMR 15.203 a) Design flow of existing system gpd Approved? _L res approval date 1-7-10+ no why? b) Design flow of proposed upgraded system 4qv gpd c) Design flow of facility gpd 6) Proposed upgrade of existing system is a) Voluntary Required by order, letter, etc. (attach copy) _L,,/ Required following inspection required by 310 CMR 15.301 (provide date inspection form was submitted to the approving authority) &-N-©l (date) b) . Describe the proposed upgrade to the system i; yrs t r Iry c L hknfjj% -FAA) 7"Het 210 J C c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per. inch (state actual pert rate) ner are OM rout . U"M PAGE 3 OF S MA, Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) 4A Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & pere rate) -f 3 1 6 W1. Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the Code) System upgrades that cannot be performed in accordance with 310 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 -CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves -a reduction in the required separation between the bottom of the soil absorption system -and the.high groundwater elevation, an Approved Soil Evaluator must determine the. high ground water elevation pursuant to 310 CMR 15.4050)(i)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater ' feet As determined by: Evaluator's name Evaluator's signature Date of evaluation 7 7�-Fl -- !�7 PAGE 4 OF 5 8) Notice to Abutters No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property or well is affected by certified mail at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the Department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the Department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. List of affected Abutters: Abutter Name Address Date notified Abutter Name Date notified Address Abutter Name Address Date notified Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible: Fu��- C�o�t P�� w�'� s�LT /,j . 0 pcc� L6 eA rC e. 11-167 OZ15VIAX i WA4- %� f q b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: 7 Do "MOV® FORM - U10195 PAGE s OF S C) a shared system is not feasible: d) connection to a sewer is not feasible: 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? _yes r/no 11) Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." Facility owner's signature Date or ox Niini of.preparer Date Telephone # & address of preparer NOTE: Title 5, 310 CMR 15.403(4), requires, the system owr4r or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. DW "MOVea FORM-12MI95 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director October 17, 2001 William Dufresne Merrimack Engineering Services 66 Park Street Andover, MA 01810 Re: 37 Anne Road, North Andover, MA 01845 Dear Mr. Dufresne: Telephone (978) 688-9540 Fax (978) 688-9542 This letter is to notify you that the following variance has been granted for the site at 37 Anne Road. • Separation to groundwater from 4 feet to 3 feet Please note that with this variance (separation to groundwater) that no additional rooms may be added to the dwelling unless it is tied into sewer. The Board of Health requires that a deed restriction be placed on the deed with a copy to the Board of Health before a Certificate of Compliance can be issued. With this variance the plans for the septic repair dated 10/09/01 are approved. If you have any questions, please feel free to contact this office. Sincerely, Sandra Starr, R.S.,C.H.O. Health Director cc: Pratt File SS/aero BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 3 7 P lf��l relative to the application of n S4o) dated /6 o/ for plans by Pler111 066k and dated 6 with revisions dated 2 I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be. submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. . b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer -J' Date: /25` Disposal Works Construction Permit # o'� o Location: owner's Name:GAg6 % (yt a2 p Map/Parcel:7A) 5y- Address:--- 3Z 01PL)e VAP Installer. Tel -: New (sisa)Repair Date: 7 %,! Wetlands'?' iow► Zone II —"' Soil Svmbol_!S_U_Soil Rame Soil Class Deep Observation Hole Logs Elevation Depth Soil Horizon Soil Te=ture Soil Color Soil hiottlin; %Gravel, Stones, etc; ?,d G V Gv ¢.. F, 2, gY 5/tt _ 4n-135 62 69,. L•5. Y F/ 1'LtaxoeG 5y 4/3 '7-51e V. FWAA" I �� �p�,g5, t�► �t� ��k55► r u B IParent )Material Depth to Bedrock=StandinZ Nater in the Hole: n Weepin.. from Pit Face FSHGIy. Parent Material Depth to Bedrock Standing. Water in the Hole: Weeping. from Pit Face ESHGW; Date Observation Hole Depth of Perc Start Pre-soak- Time re-soakTime at 12" 03 Y v-l"'ue Time at 9" Time at 6" Time (9"- 6") Rate Min/Inch 1 /1 . Percolation Tests Performed Bv:_ �, t% eL, 0015 �I Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH ��} /) 320y ^"ED '.6*V L V/j� �L / O k APPLICATION FOR SITE TESTING/INSPECTION Appl ican Site Location Engineer Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. %a l S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL (978) 475-3555, 373-5721 • FAX (978) 475-1448 • E-MAIL: merreng@aol.com TO: North Andover Board of Health FROM: Bill Dufresne/Merrimack Engineering DATE: 0 -�I RE: :7�7 MAO- 9n&IF TM: TL: 64 OWNER (NAME & ADDRESS) Members of the Board: ?77 A -t JIJ C P&V*V An upgrade sewage disposal system plan dated: g' Z"O'OI has been submitted for the above referenced site. Pursuant to Title 5, and the North Andover Board of Health Regulations, Local upgrade approval and/or variances are being sought from the following sections. 1) 1 !�-' 204 vewric4-c- Ir-rw 5-4'- 'ra- 155'.U.I" `f I #a -Z-' 2) 3) Please consider these requests for approval on your earliest available meeting agenda. We respectfully request your consideration of these matters. Very truly yours, MERRIMACK ENGINEERING SERVICES 19I- - Lt2�&� William Dufresne cd TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director June 26, 2001 RE: Letter of Noncompliance - Notice of Septic System Failure at 37 Anne Road, North Andover, MA 01845 To Whom It May Concern: i ,10PT#1 1 � A 4SSACMu�Et Telephone (978) 688-9540 FAX (978) 688-9542 The North Andover Health Department has received and reviewed the Title 5 Inspection Report that was generated from the inspection of the septic system at 37 Anne Road, North Andover, MA on June 14, 2001. Your inspector has determined that your septic system is failing to protect public health or the environment according to Title 5 of the State Sanitary Code. You are hereby required to retain the services of a Massachusetts licensed professional engineer (P.E.) or Massachusetts registered sanitarian (R.S.) to design a new septic system in compliance with Title 5 and North Andover Board of Health regulations. Please be advised that you have two years from the date of the inspection to complete the necessary upgrade work. However, please be aware that if the dwelling at this location is currently vacant, it may not be re -occupied until the septic system has been repaired or the site connected to municipal sewer. It is recommended that you hire a septic hauler to periodically pump your septic tank until such time as a repair can be completed. The Board thanks you for your willingness to help protect the environment, the ground water and public health. Please do not hesitate to call the Health Department office at the number above if you have any questions. Sincerely, , Sandra Starr, R.S., C.H.O. Health Director Encl. P.E. list Hauler list Brochure Cc: File COMMONWEALTH OF MASSACHU TTS' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA;;� - / E� I DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 3'1 -4M/JE o 6o Owner's Name: 4 �� Owner's Address: Date of Inspection: Name of Inspector: (please print) Re n, -s v4M %" C- Company Name: N ZW �N &":k N n kZ_N&LAi c Yuiv &- Mailing Address: 6g>c.,' g Eec l-1 W OO n 09 -WC Telephone Number. gz3—_C206— / Z 9 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ,� J/4/01 The system inspector shall submit a copy of this in ion 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. TC,(01 OF te"-) t OAWp L Notes and Comments r- ��� d 2 2001 ****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 nndo`ent conditions of use. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ 97 A N ro L �Z D No 2TH A� flck.an Owner. Co w 0o4 oen Date of Inspection: 41 Inspection Summary: Check A,B,C,D or E /ALWAYS complete all of Section D -'k. System Passes: I have not found any information which indicates that any of the failure criteria d ibed in 310 CMR :15.;303 in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated beloents: B. System Conditionally One or more system comp ents as described in the "Conditi al pass" section need to be replaced or t; repaired The system, upon completi of the replacement or as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,NDXthe foy'�.he following statements. If "not determined" please explain. The septic tank is metal and over 20 years of or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infil" Vis ion tank failure is imminent. System will pass inspection if the existing tank is replaced with a compink as a roved by the Board of Health. *A metal septic tank will pass inspectiucturally und, not leaking and if a Certificate of Compliance indicating that the tank is less than 20'vailable. ND explain: Observation of sewage Obstructed pipes) or due to a approval of Board of Health ND explain: or break out or high static water i settled or uneven distribution box. broken Pipe(s) are replaced Obstruction is removed distribution box is leveled or replaced in the distribution box due to broken or; em will pass inspection if (with 1>6 system required pumping more than 4 times a year due to broken or obstructed pass m9pection if (with approval of the Board of Health): broken pipe(s) are replaced Obstruction is removed ND explain: The system will i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,3 7 �A s N e 20 1.102nd ANPOyleA- Owner: 0 M ybofMIA2 ocn'h 0 e, Date of Inspection: (a 1 of C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to #fermine if the system is fa' ing to protect public health, safety or the environment. 1. tem will pass unless Board of Health determines in accordance with 10 CMR 15.303(1)(b) that the sys m is not functioning in a manner which will protect public healt ,safety and the environment: #;, CISKM 1 or privy is within 50 feet of a surface water ��� _ Ces of or privy is within 50 feet of a bordering vegetated v0etland or a salt marsh 2. . Systei*will fail unless, the card of Health (and Public Water Supplier, if any) determines that the system is functioning in a mane hat protects the public health, safety and environment: The system has a septic tank an �Vabsorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to as ce water supply. The system has a septic tanl�and SAS an e SAS is within a Zone 1 of a public water supply. _ The system has a sept' tank and SAS and the S. is within 50 feet of a private water supply well. The system has tic tank and SAS and the SAS is than 100 feet but 50 feet or more from a private water supp well**. Method used to determine d' **This syst passes if the well water analysis, performed at a D certified laboratory, for coliform bacteria volatile organic compounds indicates that the well is free om pollution from that facility. and the pr ce of ammonia nitrogen and nitrate nitrogen is equal to or less an 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this rm. 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: _37 A n n I= fLc-7 dJoMmi J V C {2i Owner: am 14L Date of Inspection: oAlol 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 –!C 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 V% Liquid depth in cesspool is less than 6" below invert or available volume is less than % 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 SAS, cesspool or privy is below high ground water elevation. Any..porton of cesspool of 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. vo . 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 ?uvell 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 mltrogos 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.] (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 You must indicate either "yes" or `fid' 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. f Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _ 37 A n or Ay �1 o CL."Tli �.•� D o.� G(. Owner: ft �1-ocA h, o n Date of Inspection: Check if the following have been done. You mast 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 ? of t_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition he baffles br tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? M_ Was the facility. owner (and occupants if different from owner) provided with information on the proper aintenance 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 -)L _ Existing information. For example, a plan at the Board of Health. 4 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: 31 %fit ^0 E R o -e_Q- Owner: ?(,e_Ltcc,h 0^ Date. of Inspection: 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual):4 DESIGN flow based on 310 CMR 152of03 (for example: 110 gpd x # bedrooms): Number of current residents:- _q_ -0-C - s Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no):1p [if yes separate inspection required] Laundry system inspected (yes or no): = Seasonal use: (yes or no): p Water meter readings, if availableVast 2 years usage (gpd)): Sump pump (yes or no): Ata Last date of occupancy- COMMERCIAL MUSTRIAL 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: U Aa k h bw N Was system pumped as part of the inspection (yes or no): ,to If yes, volume pumped: Qallons - How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM -)L 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/Altemative 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: Rio ILT 10,q!b Were sewage odors detected when arriving at the site (yes or no): A0 iLA Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 "l A ru/1 v 99 or -2 Owner. to M dUMIAep, Retocr,<Y` Date of Inspection: &I uil�% BURMING SEWER (locate on site plan) Depth below grade: 7.4 Materials of construction: cast iron _40 PVC —other (explain): Distance from private water supply well or suction line: )VA Comments (on condition of joints, venting, evidence of leakage, etc.): g 1 P2 ElA c>'2 '' o SEPTIC TANK: — (locate on site plan) Depth below grade: 13 Material of construction: concrete metal — fiberglass _polyethylene other(explain) t' If tank is metal list age: _' 'is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: 1. GA 1. t_oNs Sludge depth: 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: How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 'fW.V W % f J o u. CO 1-1 P .M w s T� L L �i-71 u N d� (2, 15 dr 12-5. C)A- O 6" cel- F)N%stj &-(LAt)E GREASE TRAPgWocate on site plan) Depth below grade: Material of construction: — ____polyethylene concrete metal _fiberglass —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: 3Z R w w ti foo ti Owner. Or>wi r.,�vi (uec-,. _ rzLb a,— � o^ Date of Inspection:� I n i TIGHT or HOLDING TANK: aL (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. Qallons Design Flow: callons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: . (if present must be openWocate on site plan) Depth of liquid level above outlet invert: L 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.): e2 x ' F,Nk e i w ATU iZ PUMP CHAMBER: ALt�- (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -6'7 At N E 12a Owner: Date of Inspection: 1e of SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why. Type , leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: v,� leaching fields, number, dimensions: r t 4 r-) Ay overflow cesspool, number: innovativetalternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r�1=16110 1-Z�0)45 �1aftAA AL. CESSPOOLS: &A (cesspool must be pumped as part of inspectionXlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Jndication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: 0 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 RN N L 9,9 Owner: 4La cai' o^ Date of Inspection: ! a� 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. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 &)j)a 6 ren No2nt Avoo%E2 Owner: grlpm&wecti / Co �. f ^a,\ Date of Inspection: _ o SM EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet P➢ Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: 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: 97 '.1 iI + L.