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HomeMy WebLinkAboutMiscellaneous - 37 WHITE BIRCH LANE 4/30/2018 (2)MAP # LOT #�_--.__.�__._.__._..__..._.__ PARCEL # STREET�._...�.......... CONSTRUCTION ARRAQVA!, HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE PP. BY._ _ DESIGNER: �/� �P��/A/�`S��(% _ PLAN DATE._��Z CONDITIONS Bt/VGl�mAX' rd� SC�"7' 1 _C.�io,IG---•--- >O WATER.SUPPLY: (OWN) WELL WELL PERMIT DRILLER._..._.._-.___..._____._...._..._.._......._...---._._._.... .......... .... WELL TESTS: CmEMICAL DALE APPRUVED BACTERIA Tom. DA TE (W*,PROVED BACTERIA I I DATE APPROVED-._.____._..___.__ COMMENTS FORM U APPROVAL: APPROVAL TU ISSUE" E NO DATE ISSUED � 97 BY CONDITIONS: /GL Tb --Z3 d5f_ CNS: hM 4,6<_ — FINAL APPROVAL:. ALL PERMITS PAIDYES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL 1GE� NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: a 5E? Q� r .T • it \ .. t t F ..- .1 i.. ti..: +'.• i. _. •-.,., .; �i _A- _. .. - IS THE INSTALLER LICENSED? 1—YES NO ',..TYPE OF - CONSTRUCTION L- W REPAIR s' . - ,. :..NEW CONSTRUCTION:,.,. CERTIFIED PLOT PLAN REVIEW YES NO - CONDITIONS OF..APPROVAL NO f f _(FROM .FORM U) ,. .,ISSUANCE OF DWC PERMIT. _. c NO t DWC PERMIT N0. K INSTALLER:}��� ".:BEGIN INSPECTION YES N0: " =:EXCAVATION, INSPECTION: :NEEDED: vt ,PASSED BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: APPROVAL. TO BACKFILL: DATE: �� BY -L.GRADING APPROVAL: PATE ✓ BY .ETNA • DATE: CONSTRUCTION APPROVAL:ell BY .FINAL �,::� TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 TOWN OF f JUN 19 IS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Address of Property: W/-117-6 .8)k-(0 kAde Address of Owner: (if different) Town: �0- Avi,--oveg , MA Owner's Name: R06c—zr ¢- &Jk> Fat% tlAS�NSKI Date of Inspection: 6-10 — 9z ❑ Voluntary Assessment Name of Inspector: �� ANN/ N_ 7�/)' tj O (Not Reported) Name 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 Inspector's Signature: Date: (-1 D— q -7 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 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not). N The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, ortank 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. TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3;? b(l iim &fte4 Lv-z ly-- fits, % Owner: CC_ 1AS<I Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled, or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are placed obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 than 5 ppm. t, TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 37tt 14)7 8�k6f) LSI/., N• Owner: 1 . Date of Inspection: 6-1p—q7 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). `Number of times pumped Any portion of the soil absorption system, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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: The4otlowing"criteria epply.to large,systems in addition to I -he criteria above.::.' ;. 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 suf ace drinking water supply. The system is located in a nitrogen sensitive area (Interim Wellhead Protection Area {IWPA) or a mapped Zone II of a public water supply well). The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. The intent of 310 CMR 15.302 is to provide reasonable guidelines for the inspection of existing systems in as non -intrusive a manner as is possible to avoid damage to the system and any unnecessary disturbance of the surrounding soil area which is related to the treatment process. The inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the new owner. The inspection criteria are intended to allow for timely inspection to avoid undue delay in the transfer of property. I understand that this report does not constitute a warranty or guarantee of future operation. Client or Representative Date I TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 37 ti,4;bTL' &/" a., AI. 4�tik , YA Owner: R. d4sws</ Date of Inspection: 6—/p Check if the following have been done: _-Z Pumping information was requested of t owner ccupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. zThe system does not receive non -sanitary or industrial waste flow. zThe site was inspected for signs of breakout. All system components, excluding the soil absorption system, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ""T 'ze� I I location of the soil absi7rption system on the site hasbeen determin ed basedto exi�tin informatio or approximated by non -intrusive methods. C� The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of subsurface disposal system. 4 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 7 MJ,41 7-C &r(*4 Carl- / -. Atz "-iZ Owner: R. As/AW5<1 Date of Inspection: 6-10-17 tra .fi FL* . lfll' CONDITIONS. RESIDENTIAL: Design flow: gall ns A107—,5t�W�/ CW ZY24 WIAI& Number of bedrooms: 1z Number of current residents: Garbage grinder: (yes or no) Laundry connected to system: (yes or no) Seasonal use: (yes or no) A16 / Water meter readi s, if available: 51f7 2 Z z Z 7 P6 -k' -1''�N Last date of oc pancy: R COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: 2-1 : /o OTHER: (Describe) i Last date of-bccupaticy:4' GENERAL INFORMATION PUMPING RECORDS and source of information: Pr/M� z yes aZtke2-- System pumped as part of inspection: (yes or no) ND 4 If yes, volume pumped: gallons Reason for pumping: r 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 records, if any) Other (explain) `� 13. APPROXIMATE AGE of all components, date installed (if known) and source of information: ALL C� �� 0 ZI(-;r - --> fi Z i yizs OL6 Pee ae /& A/EYZ_ TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3i A,J hits &r<M kN., AL AAb%tK Owner: 14• JASIA161<1 Date of Inspection: 6'10-q7 IN TIGHT OR HOLDING TANK: %V0 (locate on site plan) Depth below grade: Material of construction: concrete metal FRP other (explain) Dimensions: Capacity: _ Design flow: Alarm level: gallons _ gallons/day Comments: (condition of inlet tee, condition of alarm and float switches, etc.) t DISTRIBUTION BOX:Gtl/Tib 2 rrlJ?-- (locate on site plan) Depth,of liquid level kove-;outlet-invert: + r r -' � : • + Comments: (note if level and distribution is equal evidence of solids carry over, evidence of leakage into or out of box, etc.) .-Z)-60-V- SOU lzn CAkXV QV64— ZAPID 7&Z OZP- C1-' PUMP CHAMBER: (locate on site plan) Pumps in working order: (yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 7 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 87 W�hm- 811zc4 W. , N. AA , IM Owner: R. `.iA5iiJS<I Date of Inspection: 6—/0- Q7 SOIL ABSORPTION SYSTEM (SAS):' t� (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type Leaching pits, number: Leaching chambers, number: Leaching galleries, number: Leaching trenches, number, length: ZT Leaching fields, number, dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of. ponding, Oil— IS7Jftc/ Ti a c-���` ri.L[_ - Ali) S/6m/ t MC CESSPOOLS: ND (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum Ipyer: [Dimensions of cesspool: 4 t 4� + f Materials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of inspection) M . V /%. 9 fi�Z Z*r=- IAIA. ion of vegetation, etc.) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /V0 (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.) U N TIGER ENVIRONMENTAL --%- 'ENGINEERING ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 Wq j Tia B► Rzq !.Al • , dy AM , ,qA Owner: tq- JA s s"SKI Date of Inspection: 4-- /D—Q% SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks Locate all wells within 100' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1::V01,W , . . . . . . . . . . 4o; .. . . . . . . C . . . . . . . . . .. Vis: ,3s� .. . A E, .. nJI . • ` g. . . . .a . . . . . . . . . . . . . &4 .4El . . . .. . . . . . . . . 00 G44S sEPr c - rAve, . . . . . . \. . . . . . 00, . S'A5. ARBA. . . . lsc io'. .2. L kk :�-r? �iE�r.> . . . . . . . . . . . . . . . E C) r,- . EA .. . . . . . . . . . . . . . . . . . . ................................ DEPTH TO GROUNDWATER: Depth to groundwater: Se 9) feet &ZMJ 2"N✓R" gWb 4F G /0/pE Method of etermination r ef+.• WA3:1R1:aW&V7l .' 11F,�:Z oiiiI mum aizI - 0 LOT 3 63.0' � N CT LOT 2 WALL LOT l 'U.-) WI TE BIRCH UNE F71014 ��scoP� 2�Qui�E�ENT _.. 150 DES/GN ELEI/QT/ON AT ......... (roP of 5TONE) = EX/5T/NCS ELEI rIoN HJT ......... REQU/eED f/LL a . ............................. ops/�N �s aui�T ,4S BZ111 T INVAME OUT OFI-1041,567 146.42 /NV P/PE INTO T,4MV 145.82 145.87 INV. PIPE OUT of r,4NK 145.57 M5.6,� /NV PIPE INTO 0,50X. 145.54 145.4,E /NV /o/PE OUT OF 0,30X 145.38 .1145-27 INV END 0/ -PIPE TRENCH of 145.1 144.89 I, END 144.92 GV,lTER R 6714T/ON 139. f 139. 1 AVERWOE STONE DEPT// 47 PROBE NOTE: T1//5 PLGN /5 NOT,4 141.4,P,Pt11VTY OF Tf/E SYSTEM BUT Q 1IER/F/CAT/ON OF THE LOC.4T/ON OF THE EX/STiNQ STZUCTU2ES. SUB-SU2F.4CE D/. Slm /N NORTH 14NDOPER, ILIA. FOR SCOTT CONSTRLICTION 5C.4LE: l" a 40' D4TE: 7/25/94 .C9Rl5T1Q1V5EN $ SERG1, INC. 1&0 SUMMER STREET - HAVERH/LL , MASS. . D LOT 3 WI TE BIRCH LANE \j SLOPE 7' (/50)x /50 - _ ........................... DES/CSN f'Col4nON ,4T ......... (roP of SroNE) _ ............................. EX/5T/N!� aaloT/ON QT ......... REQU/RED Felu a ............................ . 61044T/ONS oFsiGN asauar .14Q R//// T /NI/. PIPE OUT Of yOUSE 146.42 INV PIPE INTO T4NK 145.82 145.87 /NV P/PE OUT OF MAX 145.57 145.6 /NV PIPE /N.TO D. BOX. f45.54 145.45 /NV P/PE OUT OF 0,30,y 145.38 145-27 INV END OF pl E TRENCH 145.1 144.89 INV BEG. .OF PIPE TRENCH # Z /I 145.11 144.92 GVd TE2 EL E'1/d T/ON 139. f 139. f AVER,40E 5TONE DEPT/ .47 IDROBE NOTE: T1//5 PL,4N /5 NOT ,4 `t ,4,eR.4NTY OF T//E 5Y5TEM BUT ,4 vE*2/F/C.JT/ON Of T#C 4OC4T/ON OF TWE EXISTS N6 STRUCTURES. SUB-SU�F,4CE D/S SYS /N NORTH ANDOVER, IMA. FOR SCOTT CONSTRUCT/ON 5C.44E : l" = 40' D4TE: 7/25/94 CUR/ STIQNSEN SER.GI , INC. 1l00 SUMMER STREET HAVERHILL , MASS. .w 3-01 0 3 a jr N LOT 2 U' AREA=24500S.F. V LOT 3 LOT 1 w TOP OF W FOUNDATION ELEV. = 155.4' 23.6' 1 100.0' W141 TE BIRCH LANE FOUNDATION LOCA TION PLAN CLIENT: SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER,MA. SCALE:1 "=40' DATES/2/94 CHRIS TIA NSEN Q SERGI PROFESSIONAL NAL EYORS NGINEERS 160 SUMMER ST. HAVERHILL.MA. 01830 TEL. 508-373-0310 © 1994 BY CHRISTIANSEN d 'SERGI INC. I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REOUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS WETLANDS,EASEMEN7S, ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE 07HER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRIS77ANSEN & 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. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FL00D INSURANCE RATE MAP. COMMUNITY NO.: 250098 OOO5C DATE. 6/2/93 4:� DWG. NO.: 93067016 FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify 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 �� cc i �.1 T -:)/ 1 r Phone 17 ,,�V ce LOCATION: Assessor's Map Number Parcel Subdivision �&J) �l, Lot(s) Street - St. Number Use Only************************ RECO NDATIONS OF TOWN AGENTS: Date Approved Conservation Ad:ainistrator Date Rejected iI Comments Town Planner Comments Food inspector -Health Septic Inspector -Health Comore-ts Public Works - sewer/water connections - driveway permit Fire Depart -meat Date Approved Date Rejected Date Ann-oved Date Rejected Date Approved Date Rejected Received by Building Inspector Date M COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMFN�ALrpTECTION 19 AR a TITLE 5 . OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 3 W N ITE Rif -CH LW N t --L2 rz-rK !N- AU Q —V E&—, q Owner's Name: o CH pp Q L .1 Owner's Address: '47 i:'L 6 i (2C l( L1y f\,,-) Dc)oa- mfr Date of Inspection: Name of Inspector: (please print) Benjamin C. Osgood, Jr. CompanyName:New England Engineering Services Inc. Mailing Address: 60 _ Beechwood Drive, North Andover, MA 01845 Telephone Number: 978-686-1768 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 tooSection 15.340 of Title.5 (310 CMR 15.000}. The system: f �.Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �� _ Date: -3 if e 0 The system inspector shall submit a copy of this ir4on 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: 3-1 W ig ITV- j?�i 2G l-{ c." tJ 2i1 -c lir,-� 9 00 eZ f} Owner: D lam. O as N Date of Inspection: i C� o �- Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A.. Svstem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: AJ 19 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! of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 % Wy i -M 3l 2c K L�Aivc% _1Vy (l.il-4 Aj>Ov✓- t-& Owner: D F H AO Q[ N Date. of Inspection: 3l 0 N C. Further Evaluation is Required by the Board of Health: go 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(l)(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 colifor{n 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: 3 7 j u j g i a c. R L- /u N� 2il( AN':>oL;U � .MA - Owner: fl E R ✓-1a Q i ,v Date of Inspection: 311 b o Li D. System Failure Criteria applicable to all systems: You mast indicate "yes" or "no" to each of the following for atl inspections: Yes No _ _✓' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or V, clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool f Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/x 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 portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. / Any portion of a cesspool or privy is within 50 feet of a private water supply well, — Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [ f his 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.] (YeslNo) The system fads. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303, 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 `5no" to each of the following: (The followftccriteria apply to large systems in addition to the criteria above) yes no the system is vin 400 feet of a surface drinking water ply _ the system is within 200 f a tributary t surface drinking water supply the system is located in a nitr lens a area (Interim Wellhead Protection Area – IWPA) or a mapped Zone II of a public wat ply well If you have answered " s" to any question in Section E the system ' idered a significant threat, or answered `fres" in Seco above the large system has failed. The owner or operabFQf any large system considered a significan eat under Section E or failed under Section D shall upgrade the in accordance with 310 CMR 15.3 . e system owner should contact the appropriate regional office of the Dep t. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: -7 w R IT 131 e(14 LASN 1,90 2Tk A-tj Dogec ""4 Owner: cFf Q ,v Date of Inspection: Sjo N Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? V' Has the system received normal flows in the previous two week period ? ;Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out ? Were all system components, excluding the SAS, located on site ? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no /Existing information. For example, a plan at the Board of Health. _ ✓Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [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 w K %—(F e i /L(_A-( cc _A" o 0-TH ft -N C> CL Owner: Prhf An R k' l) Date of Inspection: :a & 10 u FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: '_3 Does residence have a garbage grinder (yes or no): _ Is laundry on a separate sewage system (yes or no): &Aif yes separate inspection required] Laundry system inspected (yes or no): = Seasonal use: (yes or no): AL2 Water meter readings, if available (last 2 years usage (gpd)): Sump Pump Cyes or no): NL9 Last date ofoccupancy_:e"-------------------------.------- COMMERCIAUINDUSTRIAL 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 meta readings, if available: . Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION -Pumping Records Source of information: `Z �j ca -R f e2 0 ,y c P__ Was system pumped as part of the inspection (yes or no) %Z4�) If yes, volume pumped: __gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) ("if yes, attach previous inspection records, if any) _ Innovative/Alte native 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: P .J� W Acta 9 Were sewage odors detected when arriving at the site (yes or no): &tD Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1,7 w y i rC e2cK t^ANi: 470 a--ry /)�±-JD n')c 2 n1f} Owner• CK .4(9 q t Al Date of Inspection: C� L4 BUILDING SEWER (locate on site plan) Depth below grade: j e Materials of construction: _cast iron _Z40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): D)P� �ou)�S ��D iti Qif1'SC..ticv� SEPTIC TANK: _ (locate on site plan) Depth below grade:_ Material of construction: ✓,concrete metal — fiberglass _-polyethylene other(explain) — Tf-6k is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_ (attach a copy of certificate) Dimensions: /,5'60 &.fly Sludge depth: z Distance from top of sludge to bottom of outlet tee or baffle- Z j Scum thickness; 7— Distance Distance from top of scum to top of outlet tee or baffle: G� Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: oKg�A-s v 2e sn < c4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): &V-) 0. Gd "vcice- -s !.N 6-0aD GREASE TRAP: �ocate on site plan) Depth below grade: — Material of construction: — _ concrete metal fiberglass polyethylene other (explain). Dimensions: Scum thidrness: 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 umpingComments (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: ?,-7 w K i -.-e- 13IRCt-t t_,a,e- iu o 2 T14 ZkL2CmEj? - ,4-1, . Owner: J E H 1-0 Q t N Date of Inspection: :31 ti, ( zy 11GHT or HOLDING TANK -.,L± (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 BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): Cv,!NbIT-1l3 n COuee— COnCKeo 4,00 Silo 6 A L �Z�PL��L c7. a>csi Rt�ulorl 4�.>>4(.e n,u Eui E/_Cf b i— bc aV-F4G-r% O2 s C,cCLS cAyzs�j oveR- PUMP CHAMBER:A�(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: 37 w i-fT-r- ? t a.Q-C NoP- H ove2 Owner: fl E hP stn Q1 AJ Date of Inspection: 311(, J a y 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. _Teaching trenches, number, length: 2 C, «) leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Typelname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): (}2614 or —jaFUCNr 5 S ^.DJ,44 r4L N0 el) AJ 9.NCG- -531 CESSPOOLS: AIA (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: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:1�/9" (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.): I a Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 7 w. K (-TF S r U K L ,) 6 - Owner: Date of Inspection: 3 lac J3 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. (3 'To I- AN y- 35� 5� �i6� 7t2,015 ,.D - F, ox Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 -1 W At t;L�7 a I tic H L� �rE N o R -?k 6,,j D o, -e2. Owner: r,,C--H #f0 Q4 nj Date of Inspection: ?21)(-16 y SM EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6 feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on reed - 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 mast describe how you established the high ground water elevation: )CSA 6-N A, --)D &5 13 L), i, ( I ^JD ) cA-i� c v�4 i�r /Z- i?R2�5'GF & - v 7 RfZyw FLANS 126T2FD 7 2s 9`% `1• ��. . �,.�'.tY ,+G` I� � Ypy}i �'�. �'�t'� L� �'� y1 t.`1<1 ���,, 1;.t, Yom? l 1 �tS+.`� p�`�. E.Y� -^y �}ll`'1 �..� ... • . ... .. a -,S ;'ate ih�.�i' idtl. � �4+�t!i�*''6+��'7��}l?' i;'�(t'y,' `��..a l�� ZS. � ���19'�s7tity�rc � y��.4xa« tf �ti .. - ,. `,� t • ! a. 1,y f YS�1 it � '. t\ i 1 .� � �n. I- r 11- t 4 .r Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH NORTIi n,,,u F'jimeamm T p ♦ - r DISPOSAL WORKS CONSTRUCTION PERMIT SSCHuse Applicant TELEPHONE NAME ADDRESS Site Location ;DT— Permission is hereby granted to Construct-( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee C IRMA ,BOARD HEALTH D.W.C. No. G -7 (c f HORTq 1 o } no SSACHUSEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant_ Test No. Site Location nT Z w �, �lA l•,4.-�� Reference Plans and Specs. ENGINEER DESIGN T� 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 Site System Permit No. �Oc xii `s BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext 2 3 November 15, 1993 Phil Christensen 160 Summer Street Haverhill, MA 01830 RE: Revision Fees on Lots #1//2 � 4 White Birch Lane Dear Phil: This is to notify you that your septic plans for Lots #1, 2, 3, 4, 5, and 6 White Birch Lane have been rejected. Please see attached sheets outlining what is needed for approval. In addition, revision fees are required for Lots # 1, 2, and 4 White Birch Lane. The fee for re -submittal is $25.00 per plan, which will total $75.00. Please make check payable to the Town of North Andover. If you have the Health Office. SS/cjp any questions, please do not hesitate to call Sincerely, Sandra Starr Health Agent DATE �C /�� �I� Sheet of / BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED APPLICANT fl ASSESSOR'S MAP ADDRESS PARCEL LOT # STREET ENGINEER /V, /5 /-,,A ADDRESS 1;,if12 PLAN DATE --c `i REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED Al, 6 v zwl_a No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 RECEIVED MAY 18 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Date Name & Address Z- Gallons Comments 5 -Apr Andriolo 37 irch Lane 1500 Good Sullivan 47 Boxford St 750 Good 6 -Apr Saplenza 40 Sterling Ave 1500 Heavy bottom 9 -Apr Disalvo 400 Winter St 1500 Good 10 -Apr Sarano 265 Hay meadow Rd 1500 Xxxsolids 12 -Apr Lind 575 Winter 35(. 16 -Apr Distefano WA Raleigh Tavern Lane 1500 Good 1000 HG Walsh 58 Paddock Lane 1500 Good 18 -Apr Schrader 35 Woodberry Lane 1000 Good Ahlhdm 48 Hawkins Lane 1000 Good 19 -Apr Barrett 235 Candel Stick Rd 1500 Good 20 -Apr Harold 453 Forest St 1500 Good Duffy 67 Shirwood Dr 1500 Good Zoll 333 raeligh Tavern Lane 1500 Good 23 -Apr Haffeners Car wash 564 Chickering Rd 2000 red tank 25 -Apr Valle 58 Evergreen Dr 1000 Good 27 -Apr Lucas 39 deer meadow Rd 1500 Good 30 -Apr Meaney 745 Foster St 1000 Good RECEIVED MAY 18 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT