HomeMy WebLinkAboutMiscellaneous - 4 EVERGREEN DRIVE 4/30/20184401
0 0
Town o
f North Andover
HEALTH DEPARTMENT
3 C US
CHECK #: DATE:
LOCATION:
d,
H/O NAME:
CONTRACTOR NAME: C
Type of Permit or License: (Check box)
• Animal
• Body Art Establishment $
0
Body Art Practitioner
0
0
Dumpster
$
Septic - Design Approval -
$
13
0
Food Service - Type:
$
0
Funeral Directors
:$
0
Massage Establishment
$
0
Massage Practice
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
0
Swimming Pool
$
0
Tobacco
$
0
TrasWSolid Waste Hauler
$
0
Well Construction
$
SEP77C Systems
0
Septic - Soil Testing
0
Septic - Design Approval -
$
13
Septic Disposal Works Construction (DWQ
$
.0
Septic Disposal Works Installers (DW 1)
$
0
Title 5 Inspector
$
0
Title 5 Report
$
0 Other (Indicate)
Healt ent Initiali3
Agent Initi
White - Applicant Yellow - Health Pink - Treasurer,�,
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
—Q
PA
Commonwealth of Matsacl;usetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner's Name
North Andover MA 01845 12/4/2009
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Chad Jablonski
Name of Inspector
Jablonski & Sons, Inc.
Company Name
237 Merrimac St.
Company Address
Newburyport
Cityrrown
978-360-9358
MA
State
4574
Telephone Number License Number
B. Certification
01950
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Date
The syst0h inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Healt EP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
nforma
equine fo
d for tiis
requireNorth Andover MA 01845 12/4/2
every page. City/Town State Zip Code Date of
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SAS and all Components in good working order
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
009
Inspection
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SAS and all Components in good working order
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
information is
required for North Andover MA 01845 12/4/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool of privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner's Name
North Andover
City/Town
B. Certification (cont.)
MA 01845
State Zip Code
12/4/2009
Date of Inspection
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 hat. 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
nformarequired for tion is
requireNorth Andover MA 01845 12/4/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 or 17
i
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
information is
required for North Andover MA 01845 12/4/2009
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 gpd
l5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
information is
required for North Andover MA 01845 12/4/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd))� Q-' c
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes ® No
Occupied
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
15ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y 4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
information is
required for North Andover MA 01845 12/4/2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
North Andover BOH
❑ Yes ® No
na
gallons
na
na
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner's Name
North Andover MA 01845 12/4/2009
Cityf own State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
15 yrs- Certificate of Compliance dated 8/17/94
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line:
[Nowa— 11111[m
Under cellar floor
feet
na
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Watertight at foundation
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
If tank is metal, list age:
❑ fiberglass
52"
feet
❑ polyethylene ❑ other (explain)
na
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10. 5' x 5.5' x 5.5'
Sludge depth:
A
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
information is
required for North Andover MA 01845 12/4/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
measuring tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank structurally sound, inlet and outlet tee's in good condition. Pumping recommended
Grease Trap (locate on site plan):
Depth below grade:.
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
❑ fiberglass
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:
feet
❑ polyethylene ❑ other (explain):
Date
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner's Name
North Andover MA 01845 12/4/2009
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
❑ fiberglass ❑ polyethylene ❑ other (explain):
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
,p
Property Address
Sarcia
Owner Owner's Name
information is North Andover MA 01845 12/4/2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
0"
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.):
Box is level and distributing equally
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner
information is
required for
every page.
t5ins • 09/08
Owner's Name
North Andover MA 01845 12/4/2009
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
®
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
❑
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
3
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
no sign of hydraulic failure or ponding
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Owner
information is
required for
every page.
t5ins - 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner's Name
North Andover MA 01845 12/4/2009
Cityrrown
D. System Information (cont.)
State Zip Code Date of Inspection
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for
every page.
t5ins • 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner's Name
North Andover MA 01845 12/4/2009
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand -sketch in the area below
❑ drawing attached separately
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
information is North Andover MA 01845 12/4/2009
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
0
u
Obtained from system design plans on record
If checked, date of design plan reviewed: Plan approved 8/18/93
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Perc/Deep Hole test performed 5/12/93 by S. Durso and witnessed by S. Starr
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Evergreen Dr
Property Address
Sarcia
Owner Owner's Name
information is
required for North Andover MA 01845 12/4/2009
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 12!7/200911:44:37 AM by Lisa Evans Page 1
Town of North Andover
F Tax Map # 210-107.C-0029-0000.0
Parcel Id 18312
4 EVERGREEN DRIVE
SARCIA, E.
4 EVERGREEN DRIVE
NO. ANDOVER, MA
01845
Class 101 Single Family
Property Type
1 Residential
Size Total 3.45 Acres
FY 2010
UB Mailing Index
Name/Address
Type
Loan Number
Active/Inact. From
Until
SARCIA, E.
Payor
4 EVERGREEN DRIVE
NO. ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 13510.0 - 4 EVERGREEN DRIVE
Last Billing Date 11/3/2009
1090064
01 Cycle 01
Active
UB Services Maint.
Account No. 1090064
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE 26.60
/1
UB Meter Maintenance
Account No. 1090064
Serial No Status
Location
Brand
Type Size
YTD Cons
16748923 a Active
00
w Water 0.63 0.63
65
Date
Reading
Code
Consumption
Posted Date
Variance
10/23/2009
559
a Actual
7
11/11/2009
-26%
7/23/2009
552
a Actual
9
8/12/2009
-39%
4/27/2009
543
a Actual
16
5/13/2009
12%
1/23/2009
527
a Actual
14
2/10/2009
43%
10/23/2008
513
a Actual
10
11/12/2008
6%
7/21/2008
503
a Actual
9
8/15/2008
-39%
4/22/2008
494
a Actual
14
5/19/2008
5%
1/28/2008
480
a Actual
15
2/19/2008
26%
10/24/2007
465
a Actual
12
11/16/2007
2%
7/19/2007
453
a Actual
11
8/15/2007
-26%
4/19/2007
442
a Actual
13
5/21/2007
-13%
1/29/2007
429
a Actual
18
2/20/2007
21%
10/25/2006
411
a Actual
14
11/16/2006
-29%
7/27/2006
397
a Actual
19
8/18/2006
9%
5/1/2006
378
a Actual
18
5/16/2006
8%
1/31/2006
360
a Actual
18
2/13/2006
30%
10/26/2005
342
a Actual
14
11/9/2005
18%
7/20/2005
328
a Actual
11
8/10/2005
-32%
4/20/2005
317
a Actual
15
5/13/2005
-9%
1/26/2005
302
a Actual
19
2/15/2005
-6%
10/21/2004
283
a Actual
19
11/15/2004
6%
7/22/2004
264
a Actual
15
8/25/2004
-1%
j.�
_
Cornmonw=aith of Massachusetts
City/Town of No andover
x a
W
System Pumping Record
e
M
Form 4
I
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information _
Important: When
filling out forms
1. System Locution:
on the computer,
use only the tab
_T l%2 (�j r
Le
-_�l
key to move your
Address
cursor - do not
No Andover w.-- • -
key.
City/Town Stateip Codi `
2. System Owner:
r�
Name
Address (if different from location)
City/Town State.
Zip Code
Telephone Dumber
. Pumping Record
1. Date of Pumping / - 3 500
p g Date 2. Quantity Primped: --�-
Galions
3. Type of system: ❑ Cesspool(s)ht Tank ❑
Septic Tank ❑ Tight Grease Trap
Other (describe);
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes [] No
5. Condition of S-strrri-
6. System Pumped By:
Name -��-. _
Vehicle
Stewart'sSeptic; Service
Company
7. 'Location where contents were disposed:
0 So. Mill
Signature of Nauier
Signature of Receiving Facility
Ma 01
Date
OWN OF NORTH ANDOVER
HEALS �P R ME. T
pate
t5form4.doc^ 013/06 System Pumping Record • Page 1 of 1
1
MAP # LOT #
STREET -'Vel
PARCEL#____.._.._...._...____.._...._...._.._..........
CONSTRUCT LON__..APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? YE NO
PLAN APPROVAL: DATE_c� /8/ APP. BY--.Z-
DESIGNER:
Y--DESIGNER: /V �V& As64C r PLAN DAfESAg-
COND I T I ONS -- --'--
WATER SUPPLY: TOWN—� WELL
WELL._PERMIT DRILLER.-..--. ........ _....._..____.... _.__._........_...._ _.__..._.............._.... __..
WELL TESTS: CHEMICAL DA1 E AI `P RUVED...______..__ ..........
BA A I DA I E (IPPRUVED
BACTERIA II ATE APPROVED-_.___.__
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSUE" (TESJ NO
DATE ISSUED q 4 _BY/��✓v.._.._._...____.._�
CONDITIONS:
FINAL APPROVAL:..
ALL PERMITS PAID E5 NO
WELL CONSTRUCTION APPROVAL �YES NU
SEPTIC SYSTEM CONSTRUCTION AP.PROVAL'�. NO
OTHER YES NO
ANY VARIANCE NEEDED YES NU
FINAL BOARD OF HEALTH APPROVAL: DATE:% / ��BY:..._.
Commonwealth of Massachusetts
City/Town of NORTH AiUDOVER MASSAC �[S"
System Pumping Record
Form 4 SEP - 6 2006
DEP has provided this form for use by local Boards of Health. The Sps�tsaMFPI?riyfr�c' � mu;
.be submitted to the local Board of Health or other approving authori y� EALTrI c>EF Let„ rw t
A. Facility Information -
Important:
When filling out 1. System location:
forms on the
computer, use
only the tab key Addr ss
to move your
cursor . do not -"-- _
use the return City/Town
key.
2. System Owner:
Name
A6" Address (If different from location)
Clty/Town •--...---- _ __---- State
Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Type of system: ❑
❑ Other (describe):
75 e --
Date 2. Quantity Pumped:._. _._.. _.
Gallons
Cesspool(!) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Ye -�No
r
5. Condition of System:
If yes, was it cleaned? ❑ Yes ❑ No
v
6. Sy em Pumped By:
ame- - _
Vehicle License Number
c5t a jm�,
Company
7. Location where contents were disposed:
Pw
Sig
i ature of Haug ..—_,_.._._. U 2��(�
_�._.__._._. ._..__......--- -
http://www.mas$,gov/dep/water/ provals/t5forms.htm#inspect Date _ '- ---- --
t5form4.doc- 06/03
System Pumping Record - Page t of
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
'A"ge-, '5- - "-Lzi--
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Test No.—
Sitel-ocation
Reference Plans and Specs.7-- llle!5-W�-
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to bie installed
in accordance with regulations of Board of Health.
Fee A��,O. 02)
f zzc-u�
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 0/x-9
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
Neve Associates, Inc.
447 Old Boston Road
Topsfield, MA 01983
Dear Tom:
TEL. 682-6483
Ext. 32
August 5, 1993
The recently submitted plans for Lots 1 & 2 Evergreen Drive
have been disapproved for the following reasons:
Lot 1:
1. Elevation of foundation drain missing. (N.A. 6.02v)
2. Basement floor not a minimum of one (1) foot above
groundwater elevation. (N.A. 4.20)
3. Need additional percolation test at deeper elevation for
soil change.
Lot 2:
1. Elevation of foundation drain missing. (N.A. 6.02v)
2. Bottom of chamber excavation not 4' from seasonal
groundwater.
If you have any questions please do not hesitate to contact
the office.
Sincerely,,
Sandy Starr
cc: Fred Saraceno
Karen Nelson
( .. ... .... ,. 4 r• y ,� �..�� 9��, y �� ti �� �cz ;i` ; 3 x ""s ,x?�"'c�``'�i ''.t"`�"tC,� : .
i .�.c:vi�a �« ii$ :.a��th�x'kg1�i,2 a .1,. .•<•"�t ��. .
NORry
�+
L
'�.y °•ono ..""�°j
SS�ICNUSEt
Town of North Andover, Massachusetts Form No. 3
BOARD OF HEALTH
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant
NAME
Site Location_ I P-1— -7t
A
Permission is hereby granted to Construct K ,�
Sewage Disposal System as shown on the Design Approval ro alrI S.S. an Individual Soil Absorption
S.S. No.
6D
Fee iL
CHAIRMAN, BOARD OF HEALTH
D.W.C. No. Eofol—'
v+a e
i
V A
ad
o
s
O N
C3 A=
R 0.�
v v
� =r_L
tt!So. FO�Cwe
�
N zoo.—
• � � magi
Ne %.
N
0 CD
c�
ts cm
CD c
o. =
CO3 m
O N =
N m 3 ..
� J N
C m O
R
N
U
= G c
N R O
- N
A7 E
4i
N m ;
= o o,
m" G
� ca °v
mor m
V N OZ C
�
cmcol
CL
Q y m G •O
S mm p N
H p CL
N o f R
CIO C,
Z
•N O'rZ.., R C Z
t2 .� c3 fl co.� .N o
v m c m _c
COD
d
_ CNvC4 O
t $ CLO- CIO �10
z
W
W
W
J
CD i
J
a
z
o
E
:r"r+Fy -
Ey
•7•'
co
U
pG
z
v
lmw
O0-4
w
w
z
0
o
CAw
a
A
vyQ�°
O ;
� o
z
z
G
o :aCO)v
u
] 3
� r.
CD
U
a
� o
�, 2 Ca
�
a �,
N
V
z
w U
co
� �,
aj
o
w° v°Ja,
w° c40
CLCD
a°' cn w
x° w
an' cn cn
ad
o
s
O N
C3 A=
R 0.�
v v
� =r_L
tt!So. FO�Cwe
�
N zoo.—
• � � magi
Ne %.
N
0 CD
c�
ts cm
CD c
o. =
CO3 m
O N =
N m 3 ..
� J N
C m O
R
N
U
= G c
N R O
- N
A7 E
4i
N m ;
= o o,
m" G
� ca °v
mor m
V N OZ C
�
cmcol
CL
Q y m G •O
S mm p N
H p CL
N o f R
CIO C,
Z
•N O'rZ.., R C Z
t2 .� c3 fl co.� .N o
v m c m _c
COD
d
_ CNvC4 O
t $ CLO- CIO �10
z
W
W
W
J
CD i
J
a
z
o
E
`�
co
O
v
Z
C
CL
0
o
CAw
o,
z
z
o :aCO)v
CD
Q
Co m
U
z
W
>
i
C
~
OL:)
C)
CLCD
O
eoa
o a
. (k
ca
-p
ev
Q
CJ
-J 'p
z
.Q
O
J
Li-
Lc
CO)
Z CD
zCL_
V
CO)
L
O�
C
�
W
0O2
C3
F -
G
z
z
�
J
LU
W
CL
U)
Location. 4, `�JE949P
No. Date 10 Zi�q�
OKTN�
TOWN OF NORTH ANDOVER'f
A-imiWillk 10
Certificate of Occupancy
Building/Frame Permit Fee $
S CHUS
Foundation Permit Fee
(Other*Vermit Fee OAM
Sewer Connection Fee
Water Connection Fee
TOTAL
Building Inspector
1"A 7629
Div. Public Works
MONN
ti aro ,...e 0
KAREN H.P. NELSON ' o a Town of
Director
; •:. - g
NORTH ANDOVER
dUILDING
CONSERVATIO\ ,SSS`" 5E4 DIVISION OF
HEALTH
PLANNING & COMMUNITY DEVELOPMENT
PLANNING N[
DATEf
�26r 3
LOCATION
OWNER'S
CHIMNEY APPLICATION AND PERMIT
120`Main Street, 61845
(508) 682-6483
PERMIT # Z &O— C -
BUILDER'S NAME
MASON'S NAME 5 a P
MASON'S ADDRESS It
MASON'S TELEPHONE
MATERIAL OF CHIMNEY ,� js� S tf 6 Ai 1Gz c
INTERIOR CHIMNEY EXTERIOR CHIMNEY
NUMBER AND SIZE OF FLUES J U if ,?-� /
THICKNESS OF HEARTH
Will chimney or fireplace conform to requirements of the code and
have rules and regulations been received: !Ve,_�
DATE 10131
SIGNATURE OF MASO' CONTR. LIC. #
i
EST. CONSTRUCTION COST/CONTRACT PRICE
PERMIT GRANTED lO rai O � A FEE ZSR
a ROBERT NICETTA, BUILDING INSP
INSPECTED
REMARKS
r
SOLID BRICK REQUIRED
THIS PERMIT MUST BE DISPLAYED ON THE PREMISES
Town of North Andover
BUILDING DEPARTMENT
Homeowner License Exemption
(Please print)
DATE04: /
OB LOCATION
"HOL, IE01v`NER"
Number
ame
PRES'E'T `SAILING ADDRESS
Street A<
( %L—
Al e4f
f/-�
ire s
6, Lf �
Home Phone
/ ewe r�
Section of town
C�
v
ork Phone
City/Town State Zip code
The current exemption for "homeowners" was extended to include owner
-occupied d,aellings of six units or less and to allow such homeowners to
engage an individual for hire who does not possess a license, provided
that the owner acts as supervisor. (State Building Code, Section 109.1.1)
DEFINITION OF HOMEOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to
reside, on which there is, or is intended to be, a one to six family dwell-
ing, attached or detached structures accessory to such use arid/or farm
structures. A person who constructs more than one home in a two-year
period shall not be considered a homeowner. Such "homeowner" shall submit
to the Building Official, on a form acceptable to the Bulding Official,
that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1.1)
gin. undersigned "homeowner" assumes responsibility for compliance with the
State 2uilding Code and other applicable codes, by-laws, rules and
LGzulations.
the undersigned "homeowner" certifies that he/she understands the Town of
orth Andover Building Department minimum inspection procedures and
rEquirements and that he/she will comply with said procedures and
=-,_quirements . 7)
i ; LOT; ER' S SIGNATUREr�
4 �
.'.PROVAL OF BUILDING OFFICIAL
:•;oto.: Three family dwellings 35,000 cubic feet, or larger, will be
cquired•to comply with State Building Code Section 127.0, Construction
Control.
4
r .nii �A
CERTIFICATE OF USE &OCCUPANCY
Town of North Andover
Building Permit Number 236
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 4 EVERGREEN DRIVE
Date JANUARY 6, 1995
MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/2 CAR GARAGE IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUE]
ADD
N
c� -�
m
mZ
� Z
CA
z
C �
rn C
�-L CD
-n D '"h O
CD
Z d
r
Q =.
n�
� � O
D
J CD
Q
Q
C) CD
M c o0 CD
CD
m
D D C O
mMO O
O CD
z
< y
m CD
z
D
Cl)
CA
c
O
c
H
-�
CO
C7
CD
O
CD
CD
y�
CD
CO2
0
A
CCD
Ic
CD
C2
�A
w
"1
cm
w
77',j
H�_
:1
rD
cn
o
0
T
u
PTJ
m
T
a
n7
m
CcrQ
UA)
c
;�
O
n C
rij-
x
� i^
Al
co C H O O Di =
Cap I Cr CO)
» m 0 C�
CD r�„c;an 3 m
Z W =-o H --I
Oe ._► .dr CO N T
CD �o CD d o N
N
CD i�� a
> > N CD •�
� O CIS
to
o Z<f.cm,
p N CD
00 _
C S N 7�
CD O N
CD
o Ovq
C=L
co
.p+ CO)
N
C
N i
Oi tC
N N "C
CDCD
co d N :
�-t
�c
O o
CD 0
CCA .rt •�
'0 0
`���wo
c mo
ED .
v OC
c� 2
ik-
m
�Zg c=,
CD
,V
�A
w
"1
cm
w
77',j
H�_
:1
rD
cn
o
0
C C/) rz
o
w
"1
cm
w
77',j
H�_
:1
rD
cn
o
u
PTJ
CA
CcrQ
UA)
;�
C
x
C
•: y ��,,��
�J.'.r`s
y
FORM U -IDT R FORI�i
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: Phone a %a '/ J
LOCATION: Assessor's Map Number %� �`��_ parcel
Subdivision Lot (s) 2—
Street �ii�y �/r2eL�1 rQ St. Number
************************Official Use Only************************
REC0N24ENDATIONS OF TOWN AGENTS:
Date Approved 5 v
Conservation AdministratorDate Rejected
Comments
Town Planner Date Approved qq
Date Rejected
Comments
v \✓
Date Approved %cQ
Health Agent Date Rejected
Comments
Public Works - sewer/water connections ,
/O � 5�
- driveway permit
Fire Department- 7�'
0
Received by Building Inspector
Date
m
IIIIIw,F"Ij
rive
een
Evergr
oo'
o. ����
60,001 o rn
•� O p oN
o °
I
_ o
-4-�j o v
Q) o L -C) a�
QC) J
\
On
N Vi
c,k Exis ting
Foundation to
rn
m o Qa
Q 1-n
U
m 12-
10 p
V a�
� II II II II o
(f)Qm Qm "b -N w
U LO C V
O
Q) eco N� 0000 Ib Q� �n
Ir") (z) \ II �N "JQ(Zi � +Ld
y�sr awl
4 II II II oN II �oNNN s cQ LO
Qm Qa0 O� II j�ON II II II ` a� o O
c�ON o 6
� r•j NCp
�� ")cp '16 @)���0 aUUa G
lb
cw o o�
Qm Qm ���nOa�'I-Z�
X>
PLAN REVIEW CHECKLIST
ADDRESS Z,07 -,-g- CYE�G'�C�i(/ ENGINEER / • 111&U
GENERAL
3 COPIES STAMP LOCUS t/ NORTH ARROW &-,-' SCALE 4 ----
CONTOURS L PROFILE[/" SECTION BENCHMARK SOIL &
PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS &
WETLANDS WATERSHED?4/0 DRIVEWAY ✓ (Elev) WATER LINE
FDN DRAIN SCH40 ✓ TESTS CURRENT? y6- -5
SEPTIC TANK
MIN 1500G. .17 INVERT DROP L/ GARB. GRINDERl16 (+200% EDF)
25' TO CELLAR L,-� MANHOLE TO GRADE ELEV� GW=
D -BOX
SIZE
# LINES 3
FIRST 2'
LEVEL STATEMENT_
INLET��3 -
OUTLET alpd Q3 = 'A0 (2 "
OR .17 FT)
TEE REQ' D? �s
LEACHING
RESERVE AREA 4' FROM PRIMARY?(/ 100' TO WETLANDSy 2% SLOPE
100' TO WELLS �'� 35' TO FND & INTRCPTR DRAINSc/ 4' TO S.H.GW�
325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY 1--�
MIN 12" COVER c/ FILL? (25' if above natural elev; 101if below)
BREAKOUT MET?
TRENCHES
MIN 660 gpd SLOPE (min .005 or 611/1001) >3' COVER? - VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN
TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE?
BOT X LDNG + SIDE X LDNG = TOT
(L x W x #) (G/ft2) (DxLx2x#)
l� p
-Gocr� c1CAl
�5T�NG G/e/gDE
DG �o
oGf /9
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
MANHOLE/PIT
= TOTAL
MIN 660 LEACHING L,,"" GW MIN 4" BELOW COVER >3 FT - VENT
MANHOLES 12"-48" STONE SPLASH PADS z/ SLOPE .005 z/
BED/TRENCH
(Bed max. 60' X 601) 2
l /
BOT 9a�83 + SIDE a�o,� l(� X LOAD = TOTAL (v 7�Co/6
(L x W x #) (2 x (L+W) x f D x #)
FIELDS
MIN 900 ft 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 X X = PUMP CAPACITY qpm
L W D Vol.
DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME
gpm
MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below
inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL
OP. SWITCH
60 7U
Sv6"3J'
6-(L
-ZFZ lCS P
S;
// - o
�'�- i C- Sim T y 5,9 IY y T/�
co)
-D 6Y 91C -7
cl, V
IN 113-1&1
DATE �/ �� Sheet- of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
�r SUBSURFACE DISPOSAL DESIGN REVIEW
FEE Y'�a od PERMIT # In 1a DATE RECEIV
EDg
APPLICANT 54- 5 U/LB6.S ASSESSOR'S MAP
ADDRESS
ENGINEER /i�� V& /9556 (-2 .
PARCEL #
LOT # 02
STREET / 6
ADDRESS
PLAN DATE 7h,3/9s REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
J , , -Z&V� gTioN or r (J�V J��E'��1U ��5si�t1G
Applican
Site Loco
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No.1
APPLICATION FOR SITE TESTING/INSPECTION
Engi neer---r&–,-�
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time M '19 V / 1?— /10 -�
CHAIRMAN, BOARD OF HEALTH
Fee Test No. 5-&V
S.S. Permit No.—D.W.C. No. C.C. Date— Plbg. Permit No.
MASSACHUSETTS
-
.::L;��;t ltrt•:i J '� 1 �,rA�.l�r:V,I1,J�,t�M)gl .',�,r,�yrEitl,!w'•';
,.t.(r;i,rti�,�`;�Y�;1; fd$�K�i1�,"iiix^�Ity,lir;i•�liF;�l:4„��°•I„A'•t:•,'�1(�' • ' '
`dEPs :F I. V•r,+yj:r.,..,•, ,.'
' provided 04 form for use by local Boards
be subml�tad to thg.local'Soard of Health or other of Health. The System Pumping Recorc m >
r,a ,.:;,;..•.:-,:>, ;;',,;;;::',,;::.,;:' ,::,,:: aPProving authority,
r
Facility ,Inforrtlon ,
.'`f;'T;•'h4n•(1�1Q:O�r .,1::::;SystBm hocatlon'; � . � . .
oNy the tab kay Address
to move your
,•�y4,,ylw,�r��i •r, sir ";`'tt:''!i''�;!��,,;i.J:' r` ;:,,,,,�:i':,' .. slat@2�P P
'
' Od@
;ii:i.. t�.�r•�i �.$�f��•!j,';•,i. 't ••S ', ,`.i kri, "•,.
•,r. :r ; 'r ystem Ow.'ne.r, :r :,•F�:' '
•`!.� �'+jr�••��,.�'��fwti.u'`�'kJ.�ni�l;ti,,�!'' •��;,n:,.�'t yy!'1' '. .
' .t..r,/ ,!d;r7•,:"!'`Air.l`larlie:':J.:,`�•I".•.,Y••71":i; r.': 't:v,. t..., ..
'"" r „ �` Address pf different from'bcaUon)
i, Ck7roWIi:•'a. :,i,' ; t'•1' Stet@'
_ ZJp Coda
Telephone Number V
i��: :.(,'t,j'. ',,):i lrSii�/:IF���'kiirl'�`7/,i(Itgi:dii41�'{I'1!�i,,1r!'"l�'•'• r, .
M' it:'t��,la•: 'r•,ii!6•. "I ,,�L:%fit:%,�{,� I �' /v/
Of Pu`
Dale 2, Quantity Pumped:
,3 :`YYPa Pfaystsm�, G410n4
~; ;r 1 1 Cesspools nk
) Ta ❑ Tight '' ,,• .,'�; •�'::.;,: t Tank
!Other (describe , 1
4r;"•Effluent Tee Fllte resent?
..{+pr ❑ Ye o If yes, was It cleaned? C] Yes ❑ N
.`i.,�...,��:., •�.. t', ti ..iii', sf jlu;t ' '�,. • ,
m',1''•'
:w pl ,.(,.y + f��)f,,J Y,1'14ri •1 J'rl�� 1/y',; 'i'�'r� :,r',' '
' � '•�' •'�''�'+%fiil•i,,(;�i��t•', 1��5:-01�i; ,''�; ;t{,,1 �d'}:.+. �•j`
._ .:,.t''..i..+•'.!!�'.lfi•IY.;t�+tcJ�l.;r,�ii'i}'�;(�lia1\``�"�:'''i�
Pimped By..
anie•rcus,i�l.,�.. 1' +rf,�
.'�.,1�`� l,�".f�
`��'r• . jY:-' ��' "�,4'�'; , � � I ��c� '-r' ���' '�• gni umb@r ,
:;,Ct.,y.• ,!� `•`S.i,�f. +.V Y14 /,.+:/,�!lµi it Y•�1Y �V171' ,'I % +'�/"a�{11, I>t.?ti, �,.��' y'.:,• i
•i�, .�'��> fl !'^'`H'�I'i1�!1(,�.1�.•.'.i•:;� 1 ���'ll'.,"•, vi"i I'
•:Tib' ,.';r r,,;r., �.t , � 1. 1, +;,�lt'.w.va't•::;t,t,;. ,•
1 t.1;•F;;; r',;:.�:7;:'. L'o on.where conlents',Were di;Q.. o
'' !•,ilr1'Ii'.:": +,.;i•',I:,;<r!f.•, Ci:1rfJi. •,�;..Ni•}i(1, 1•t„ Yp �edi � -
�.�'. �... 'r •: � i.i+' :('�'�} JCI i '�' �' 'r (�. 'i rv�r y; ` �, -
... �; �J �•iiI' "••�:,1,',, `,,,. ,dt/I •. 'i},11,;,' .!'; •lr,+,r;r�':}'�'��; � ::;,'!+' 'i, '- iti
, `_•�r,1.•. i.'?'if11 ;; Ji•�.�'.Jli•,lir pi'ki,i,N � ,P ''�' ,
J`., :i is '•'•..., ..�:':... , i�,:w ..: 4. t b''. ',". 1. ,
�;�;�:>�i:�,3°�':+:JV:i;��,rl�•:�:;.$lQrlit� raUlB . ..
hdp�N+tivw,mass.8Wdap/v✓aler, app rova1s/16(orms,him#Inspect
t5fcvtn4,daa`OWQ3 : Syllam Pum I
PnoRecord Paye I .. .
.. .... .... .
TOWN 0F N LAI OCT 0 7 2005
U.,�'I't /m SY87-Em OWN
p M P I Q R -P- C')TK �-FFJN�CffH ANDOVER
, fl --!E
4DOR2ss
PATI OF pvkyqNQ:
QOA NTITY
t J I POOL: NO.. Y���,)Vpuc
Oy
0000 CO'NflI• rlvNVL-, 1u co
L aAc K UN
30(,1p8PLOODEv
$OL CD CA XA YQ . YU—' "fER-EXPLAIN
14M
TOWN 0F N LAI OCT 0 7 2005
U.,�'I't /m SY87-Em OWN
p M P I Q R -P- C')TK �-FFJN�CffH ANDOVER
, fl --!E
4DOR2ss
PATI OF pvkyqNQ:
QOA NTITY
t J I POOL: NO.. Y���,)Vpuc
Oy
0000 CO'NflI• rlvNVL-, 1u co
L aAc K UN
30(,1p8PLOODEv
$OL CD CA XA YQ . YU—' "fER-EXPLAIN
14M
I
N
O
U
(U
A
LL
4-
O
(1)
5 �
0
2L
42
< 0
1 O
(1)
E
L
CL
Q�
70
m
r
c
O
N
N
E
E
O
c
O
fu
i
Q)
V)
c
O
U
I
M
O
m
C
j
4
g
I
}O
V
a
a�
E
u
0
D
w
0
m
H
O.
L
7
O.
L
2 0 �
y
C
O E C
U O
m O t
DDa
1
a�
i
F=
0
a
v
U
O
O
O u O
0 Z
1 O
(1)
E
L
CL
Q�
70
m
r
c
O
N
N
E
E
O
c
O
fu
i
Q)
V)
c
O
U
I
M
O
m
1
N OF NO R
TH 'AND
SYSTEM p�1Mp--,R,,'w
NC COvM
RD
i lJL
SYSTEM LO(:AT10N —
Q of housr)
---------------
U I'C OF PUMI'INC; QUANTITY f'UmPc' D /3vo
--__CL Lu",
I'UUi. °'NO. /YES TAN
—.,SEPTIC K: NO
— Y E 5 </
�TUfZE '0 F SERYIC I ROUTINE. EMERGENCYdIt
—_
X111,>F(ZYr\TIONS, .`
CUUD CUNUITLON,. F'UILL TU CUYCIt
Firr�1%Y GK�'ASC : 0AFFLES IN I'l•acl?
ROOTS t✓EacHFIcLD IiuNuacx.•.
CXCESSI-Y .SOLIDS FLOODED
BONUS CARRYOYER HFR (Ex(La.iN) �----
CM PUMf'Cl).RY;
r �
---------------
-------------
�•u,,-lkir:�iTsl ��� •
1.
Commonwealth of Massachusetts
W City/Town of No.Andover
a System Pumping Record
Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Ma
State
U 2011
TOWN OF NORTH ANDOVER
HE-As,TtLFPARTMENT
01810
Zip Code
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping 1 ante / 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
Zip Code
Gall ns
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. s ped By:
Na a Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Steykart's Pre-treatment Plant, 20 So. Mill Bradford. Ma 01835
of Hauler
of Receiving Facility
Date
Z/ /
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
1. S m Location:
forms on the
computer, use
oniy the tab key
Address U
to move your
No.Andover
cursor - do not
use the return
City/Town
key.
tab
2. System Owner: f
Sh n/
'e"0J
Name
Address (if different from location)
Ma
State
U 2011
TOWN OF NORTH ANDOVER
HE-As,TtLFPARTMENT
01810
Zip Code
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping 1 ante / 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
Zip Code
Gall ns
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. s ped By:
Na a Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Steykart's Pre-treatment Plant, 20 So. Mill Bradford. Ma 01835
of Hauler
of Receiving Facility
Date
Z/ /
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1