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Miscellaneous - 41 CROSSBOW LANE 4/30/2018 (2)
41 CROSSBOW LANE 210/106.6-0211-0000.0 1 r i i i i Commonwealth of Massachusetts City/Town of RECEIVED ° System Pumping Record juN 16 2C Form 4 TOWN OF NORTH AN,-JVER DEP has provided this form for use-by local Boards of Health. Oth "s WvTsM2Tb e 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. A. Facility. Information 1. System Location: Left/Right front of hous Left/ ig rear of hous Left/right side of house, Left/ Right side of building, Left/Right front of bul Ing, Left/Right rear of building, Under deck Address C" /Town �Y state Zip Code 2. System Owner. Name Address(if different from location) City/Town StlZin Telephone Number 3 1 1 B. Pumping Record 1. Date of Pumping date 2. Quanti ped: Gallons 3. Type of system: ❑ Cesspool(s) a tic Tank Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No; " 5. Condition of Sy��te�m:� / 6.. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location re contents were disposed: Lowell Waste Water Sign HaulwU Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Coo IQ1U ) I 4411 / Piw�W Ft�P°�`9d Of NORTH, 6454 N � D Town of North Andover HEALTH DEPARTMENT 1SS�CNUSt� CHECK#: DATE: 2) LOCATION: -q1!4 , H/O NAME: qX J0,njj-YA\- CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $� ❑ Other:(Indicate) $ J?� Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts 11M a Title 5 Official Inspection Form ' U Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 4/15/2013 every page. 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. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name VQ 111'Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification u 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 ❑ Fail RECEIVED ❑ Neefids Further Evaluation by the Local Approving Authority MAY 2 0 2013 TOWN OF NORTH ANDOVER Cr 4/15/2013 HEALTH DEPARTMENT Ins ectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This 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-3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is North Andover MA 01845 4/15/2013 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: After permit from B.O.H., install two new steel covers on septic tank&replace d-box, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 41 Crossbow Lane Property Address Bruce,Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): 5 ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): /vv �e distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): 7 i ❑ 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): E] 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 i the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110Title 5 Official Ins i pection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 . 3/20/2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,If any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a private water supply well". i Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A'copy of the analysis must. be attached to this form. 3. Other: Inlet&outlet covers on septic tank, outlet tee in septic tank&d-box needs to be replaced. D System Failure Criteria Applicable to All Systems: Y pp Y 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•11!10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System Page 4 of 17 Pc Y • 9 I i I, Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I " 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface.water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. © ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ [] the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 41 Crossbow Lane 1 Property Address Bruce Swanton Owner Owner's Name requir atifor North Andover MA 01845 3/20/2013 required for 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 Z ❑ 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: N ❑ 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): 4 DESIGN flow based on 310 CMR 15.203 (fore 110 gpd x#of bedrooms): 600 t5ins•11/10 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 41 Crossbow Lane Property Address Bruce Swanton Owner Owners Name information is required for North Andover MA 01845 3/20/2013 everypage. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current.residents: 2 Does residence have a garbage grinder? Z 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 ears usage Yes 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last'date of occupancy: Current Date i Commercial/Industrial Flow Conditions: Type.of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: i Source of information: Pumped Nov. 2009, owner Was system pumped as part of the inspection? ❑ Yes No 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/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 i ❑ Tight tank. Attach a copy of the DEP approval. El Other(describe): t5ins•11/10 Title 5 Official Ihspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 41 Crossbow Lane Property Address Bruce Swanton Owner Owners Name information is North Andover MA 01845 3/20/2013 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years old, 11/28/1983, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 1.7 feet Material of construction: Z cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction.line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron through wall to septic tank. 3" PVC,in house, no leaks visible. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 4.1 t5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North.Andover. MA 01845 3/20/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 17" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet cover cracked, inlet tee ok. Outlet cover broken, outlet tee has corrosion holes. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of.outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ' Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Fong-Not for Voluntary Assessments 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page. Cityfrown 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 ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 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): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken, replaced. D-box has extensive corrosion holes, dirtentering d-box. Evidence of carryover. 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.): i Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ' Commonwealth of Massachusetts rh Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page.. Cityrrown. 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 fieldsnumber, dimensions: 1 field 25' x 45' ❑ overflow cesspool number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Snow covering lawn. No sign of ponding to surface. 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 i Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �r 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.). Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Crossbow Lane r e Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � it t�CC r 1� ` fl U A4� � � _ �: L�"UP IL I t1 ti t5in'S-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts ."I"itla 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Crossbow Lane Property Address Bruce Swanton Owner Owners Name information is required for North Andover MA 01845 3/20/2013 every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface'water Z Check cellar ® Shallow wells Estimated depth to high groundwater: '4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/2/1983 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan shows water @ 5' M II I I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of V I E Commonwealth of Massachusetts `Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is required for North Andover MA 01845 3/20/2013 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I i i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 3120/2013 2:49:21 PM by Karen Hanlon Page 1 `own of North Andover Tax Map # 210-106.B-0211-0000.0 Parcel Id 17606 41 CROSSBOW LANE SWANTON, BRUCE 41 CROSSBOW LANE N. ANDOVER, MA 01846 class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2013 UB Mailingndex Name/Address Type Loan Number Active/lnact. From., Until SWANTON,:BRUCE Payor 41 CROSSBOW LANE N,ANDOVER,MA 01845 I. U8-Ac qhtftint Account No Cycle Occupant Name Active/inactive Bldg Id. 17572.0-41 CROSSBOW LANE Last Billing Date 1/3/2013 3170242 03 Cycle 03 Active UB ServicesWaint: Account No.3170242 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:3170242 Serial No Status Location Brand Type Size YTD Cons. 36433681 a Active ERT HH b Badger w Water 0.63 0.63 106 Date Reading Code Consumption Posted Date Variance 3/13/2013 121 a Actual 9 24% 12/11/2012 112 a Actual 7 1/9/2013 -8% 9/13/2012 105 a Actual 8 10/15/2012 -14% 6/11/2012 97 a Actual 9 7/16/2012 -2% 3/12/2012 88 a Actual 9 4/14/2012 53% 12/14/201.1 79 aActual 6 1/17/2012 -28% 9/14/2011. 73 a Actual 9 10/13/2011 -30% 6/8/2011 64 a Actual 12 7/20/2011 6% 3/8/2011 52 a Actual 11 4/13/2011 110/0 .12/9/2010 41 a Actual 10 1/12/2011 -19% 9/10/2010 31 a Actual 13 10/15/2010 . 1% 6/.7/2010 18 a Actual 12 7/15/2010 19% 3/10/2010 6 a Actual 6 4/14/2010 -100% 1/16/2010 0 n New Meter 0 4/14/2010 -100% 1/16/2010 2449 r Replacement 6 4/14/2010 23% 12/10/2009 2443 a Actual 12 1/12/2010 -51% 9/10/2009 2431 m Manual estimate 25 10/15/2009 31% MSG 6/9/2009 2406 a Actual .18 7/20/2009 -4% 3/13/2009 2388 m Manual estimate 20 4/29/2009 20% MSG 12/9/2008 2368 aActual 16 1/20/2009 1% 9/,10/2008 2352 a Actual 17 10/10/2008 26% 6/5/2008 2335 a Actual 12 7/16/2008 .-36% 3/11/2008 2323 m Manual estimate 20 4/11/2008 -39% 12/10/2007 2303 aActual 34 1/22/2008 -7% 9/5/2007 2269 m Manual estimate 30 10/12/2007 141% MSG 6/18/2007 2239 a Actual 15 7/20/2007 -8% r y d'� III Commonwealth of Massachusetts Title 5 Official Inspection FormECE I Subsurface Sewage Disposal System Form-Not for Voluntary Assessment < I 41 Crossbow lane MAR 26 v I Property Address TOWN OF!LA NORTH ANDOVER Bruce Swanton I Owner Owner's Name - information is required for North Andover MA 01845 3/20/2013 every page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altere t ny way. Please see completeness checklist at the end of the form. Important: A General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil James Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name. VQ 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification 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 ❑ Need Fulpr Evaluation by the Local Approving Authority 3/20/2013 Injpebqo4s Sign t re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r " 41 Crossbow Lane Property Address Bruce Swanton Owner Owner's Name information is North Andover MA 01845 3/20/2013 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D. A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The.septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the I 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 Z N ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I I, Commonwealth of Massachusetts ��Zuse = City/Town of . APR System- Pumping Record TowNaFN Form 4 HEALTH D DEP has provided this form for use,by local Boards of Health. Other forms mhe 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. A. Facility Information 1. System Location: Left/Right front of hous , Le /Righ ear of hous Left/right side of house, Left/ Right side of building, Left/Right front of bul Ing, Left/Right rear of building, Under deck Address b✓\''" MCD c�C� City/Town l State Zip Code 2. System Owner. L.v Name Address(if different from location) Cityrrown Sta �- Q Zi e Telephone Number I B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location contents were disposed: WeHaule Lowell Waste Water SigDate t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I • � • S��TLED t� � • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As .of: 4/16/2013 This is to certify that the individual subsurface disposal system has been installed.in accordance with the provisions of Title 5 of the State Environmental Code: Repair of D-Box and Tee By: Todd Bateson At: 41 Crossbow Lane Map 106B Lot 0211 North Andover, MA 01845 JeTuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. ele Grant Public Health Agent - PY 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com I • ��T'fL'ED'j6a� .♦ • North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 41 Crossbow Lane MAP: 106B LOT: 0211 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box 4 TU, TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ! ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base DIDN'T SEE ® H-20 D-Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) Comments: a v ......... ..........................................•-•.....----...................................---................................................................., 41 CROSSBOW LANE Reference No: BHJ-2013-000025 Department: Permit No: BHP-2013-0612 North Andover BOARD OF HEALTH Fee Type: - Account No: 1001001.1.5. 0510.00 DWC-Component Repair PERMIT Receipt No: REC-2013-001281 .....................................................•----.....................-•------• .. ........... ... Paid By: Paid in Full On: Tue Apr 02,2013 SWANTON, BRUCE D CHRISTINE E SWAN "'....... . ......... ....' ' ' ' ' " Received.By,... Check No: 7320........................... Lisa Blackburn ......................................................................................... DEPARTMENT'S COPY Amount: $125.00 ..................................................................................................................................................................................� w • �� t; "� Commonwealth of Massachusetts Map-Block-Lot -^; • 106.B0211 BOARD OF HEALTH ----------------------- North Andover CER IFIC TE OF COM IA E THIS IS TO TIFY,That th ndividual Sewage sposal System ( air) by ---Todd Ba son r at No 41 CROSSBOW LANE --------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2013-061 Dated April-02,-2013 ----------------------------------------------------------------- Printed On:Apr-02-2013 ------------------ ---------------- -- ---- - BOARD OF HEALTH • �� ��°� Commonwealth of Massachusetts Map-Block-Lot • 106.B0211 • BOARD OF HEALTH - Permit No North Andover BHP-2013-0612 --------------- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateso-n --------- ------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. b �� 'f`�Q,Q, 1*�,�,F)y at No 41 CROSSBOW LANE `n t 1 as shown on the application for Disposal Works Construction Permit No. BHP-2013-061 Dated April 02,2013 ----------------------------------------------------------------- Issued On:Apr-02-2013 BOARD OF HEALTH ,l NORTH Application for.Septic Disposal 13 I-- °~ 9 Construction Permit — TOWN OF TODAY'S DATE . ORTH ANDOVER, MA 01845 00—Full Repair ►,°•,..°•��� 125.0 -Component SSACHJj _ Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key --A to move your Repair or replace an existing system component—What? Qo)-( � — cursor-do not use the return A. Facility Information key. p Y/ of I-as v w �N• ray Address or Lot# RECEIVED Cityrrown d. X46 V-AfZ AIX. AfPR 0 2 20 3 2.-*TYPE OF §EPTIC.SYSTEM*: TOWN OF NORTH ANDOVER ❑ Pump &4ravity (choose one) HEALTH DEPARTMENT ***If pump system, attach copy of electrical permit to application** [conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information V SWAN-vN Name y/ LI'oss 66 uv J--Ai Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Company // / Address A"y`�'✓'ems- /z� S S (S��o Cityrrown State Zip Code Telephone Number(Cell Phone#W possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 RTit Ap�licafi'on .for Septic Disposal :System '...• °c TODAY'S DATE A Construction -Perrmt = TOWN •OF * �' -«�r' �ORTH ANDOVER, MA 01845 $.250.00 Full Repair •• $125.00-Component SACHUS PAGE 2 OF 2 A. Facility.Information continued.... 5. Type,of Building: esidential Dwelling or[]Commercial B. Agreement The underslgned agrees to.ensure the construction and maintenance of the afore-described on-site sewage disposal system In accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of Norah Andover,and not to place the system In operation until a Certificate of Compliance has been Issue by this Board of Health. �Y— Nam Date Applicatio proved By oard of Health Representative) Nam Date plication Disa o ,ve for the following reasons: i For Office Use On V: 1. Fee Attached? Yes No 2.• Project A fgd Iger Obligation Form Attached? No 3, A=S.M r' rrsot Attach Ce py ofElectxical Pemlir.: Yes 4. FoundationAs BurN(hew construction•ronly); Yes o (Same scale as approvedlplan) 5. FloorPLws?(hew construction,only). Yes_ No 4-plic itibn iorp(spgsal Systerii onstroctlorl F'ertnft%Rage 2 of 2 SEP'SIC-SYSTEM.-INSTALLM-PRGJE'T MAN�'GEMEN'r OBLIGATIONS As tlie•North Andover•licensed nstaller for tfie consttuctioi�fOrlhe septic system•for.the property at: lbw Tor pluis by (Address of septic system) (En ' e. Relativd to the.application off At<d dated (in'staIleies name) n a a.e . Dated �o�—��j With revisions dated oaaBate) (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am.obligated to obtain•all permits and Board of Health approved plans:Po_r to performing any'work on a site: I must have the roved.�ilans_pt on site when any work is ''in n 2. As the installer;.I must call for any and atl'inspection& If homeowner,contractor,.project mai ager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three-64be.applicable. .' As•th nstaller,I atn required W.have.the gecessary work com�jileted prior:to the.applicable inipectioris as indicated below uffderciaand that re ue'sfin. d ihmection,without comliletion•of,the items in,accordance tuith Ti e .a. . §ul' 0: besn'•.1 ed a s :me..and or Bo'tto f B.ed Generally, this-is the brst.j1' :iutpeddon•p.nless;there is a retaining wall,which should•be dtti i :f rit: Theinstallirk:MustOpOst the iiispecdcm but does.riot have to be present. b. nstritction Irispecdoti—Engineer mbs't`i is do thei>~irtsi ection for elevations;ties;etc. '. . , As_bili of•veibil OK•(or e-mail•to:he :dpi tea, ow of 4rthandover.com):from the engineer must be subrnitted-to.the.Bo�ard�of Health,aftex•whic Jnstalter.ca3ls for.an inspection time. Installer must be present for this.inspection, A�ith•a pump::&y !te all electrical-wotk:musfbe ready and able to cause pump.to-v'ork and•alarti i to f indn on.. . c. •Fin4l`G�•—installer must request inspection tvheii'O•grading is:complete.. ;Installer'does not Nave to be onsite. 4. As-the installer,'I understand that only I�day perform the vork'(other than iim,pk excavation)and l ani required to complete the installation of the system identified in the athched.application for installation: er. a rg a,moi, --> ' ICY u.,,,�, ,,,.u.a�work done by others uiicens to•ins se tic' stems in Nnrtli Andover earl constitute reason for dei ial-gf the. tem andlorrevocation or susi5erisioni of•my license•to operate in.the Town.af N64 Andover sdkifi�Ant fines Q aU Iiersons in'v�lvetl to also' ssible. . . 4... 5.. As tlie.installer,T understand that:I�nu§t'be on-site during th�plfoxmance-,of the-following construction steps:.. a: Deterzinatfad thartheproperelevation of the a eamtion has been reached b. Inspeedon ofthe sand and stdne-to be used. c. Final inspection byBoard of ffealth saffor consultant. d. Installation.•oftank,D Box pipes,stone, vent,Pump chamber,retaWffg wall and other components. ,. 6.. as thgnstalller I• that I am sb&responsiblQ for the installation of the systT em as per the ppro ed.plani No instructions by thebomeowrier gtrieral contras oT• .otherMersons shill-absolve me Qf alas obligation. Undersigned Uceased Septic.Installcr. (Today's Date) /3 J I 1 I J�a5�f'�i BA•R 6�G,y//o ,art.c,�4.�---..�?'"_�,_..._�,[�.�4r..�..E_�.�.�. C,OM�t10 N W�QrT i kF-S 7- --- - rn In Ig N ' , s� y E sb°"`l - GR ° 5 Commonwealth of Massachusetts City/Town of XL109 System Pumping Record F Form 4 DEP has provided#his form for use by local Boards of Health. Other form m information must be,substantially the same as that provided here. Before -ryour— local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health or<othOr approving authority. A. Facility Information 1. S stem Location: Left side of house, Right side of house, Left front of house, Right front of house, eft rear of , Right rear of house. Left rear of building. Right rear of building. Address �' A)C� G1� Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town . Sta�� � � gipd� Telephone Number B. Pumping Record 1. Date of Pumping Date 'Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 1140 If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: tp-,o 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L. .D Lowell Waste Water Signature of Hauler Date t5form4.doc-06/03 System Pumping Record.Page 1 of 1 TOWN OF SYSTEM PUMPING RECORD DATE: V ✓ SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) ✓✓11 1 DATE OF PUMPING: QUANTITY PUMPED : /�4L�ALLONS CESSPOOL: NO_ YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: II GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 10 - �. SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) baA I r k dP 4�sif- DATE OF PUMPING:_ - 10 -O(QUANTITY PUMPED GALLONS JCESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: " :VdL pF NOR,- COMMENTS: OR,COMMENTS: BOAP') OF DEG 2 1 2001 CONTENTS TRANSFERRED TO: S . �'rattt ntrn�Y��llh u['h�ge�p�atua�lle "�R9purrl: Nor I �'e9 I Septic 'I"Ilk: Nu LI yes Sy110111 I'I,rtrl►e41 by: . I rt r p Address � RoSS�/ AK Title of File P69 of Date f=ile Open: -- Date fle closed: Doc Document/Action Title Date of action Refer to other P�urP.ose of Docurneent/Act nand notes Num. Document/ document/ -- Action De artrnent Board of Appeals — Board of Heal h Planning Board _ Co nservatiion commission — BoiGdin Departren,t ----� V TO: NORTH ANDOVER, MASS �g 19 �3 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at L o T 4 CR o �ss bow /A Ate North Andover, Mass. SITE LOCATION The grades and construction are as specified in apIrplans and specifications dated SE/"7 .2-/ 1983 �y 4115 VE 19S'SOC147-CS �o"\a CON/ 9. jb:6err//Reg-.- unitarian Board of Health - BEPTIC SISTEK North AntoverjNass. INSTALLATICK GHBCCK LIST LOTAPNi� •=� �,�SS�3�� OM DATF IYISAPPHO�ID AVATIC�i OK. FAIL . � easnnsi .. Tyt� G R.A.9t ExC,Q v A FAIL OK 1. Distance Tot a. Wetlands b. Drains �� �� � � lJ 721 c. Well . 2. Water Line Location 3. No PVC Pipe 4. Septic Tank - a. _Tess -_Length & To Clean Out Covers b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing molal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone 7. Lech Pits a. =zn5�16ns b. D t� co 3�$3tYZas d. ees, C. mt Pipe to Pit - Both Sides f. lean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System e. Location Xlth Regard_.to Pere Test r d. Elevations e: Water Table j Board o`!' Health - Ncrt]: :,,ndover,Masa , SUBSURFACE DISPOSAL DESIGN CMK LIST r LOT APPROVED DAA DISAPPROVED DATE Provided: Reasons: t 1 Title V FAIL Reg 2.5 The submitted plan must sbow as a rani m=: a) the lot to be served-area,dimensions lot #,abutters location and log deep observation hoes-distance to ties location and results percolation tests-distance to ties design c culations & calculations showing required leaching area 0 on and dimensions of system-including reserve area existing and proposed contours g) location any vet areas Athin 1001 of sewage disposal system or sclaimer-check wetlands mapping surf ce and subsurface drains vithin 1001 of sewage disposal stem or disclaimer i) location any drainage easements within 100' of ses,sge disposal stem or disclair'.er-Planni�ag Board files 3) sources of �.ater supply within 2001 of sewer-ge disposal e _ system or disclaimer k) ati-on of -proposed Y,-ell to serve lot-1001 from leaching facili- __ to tion of water lines on property-10' from leaching facili cation of benchmark driveways 0) garbage disposals (p _ no PPC to be used in construction profile of system-elevations of basemsnt, plumb, pipe, septic tanY., stribution box inlets and outlets, distribution field piping and Otter elevations (r) mayJ-= m ground water elevation in area se.age disposal system (s) plan rust be prepared by a Professional Ebg-ineer or other professional authorized by lax to prepare' such plans Reg 6 Septic Tanks *a) capacities-150 ' of flog, water table, tees, depth of tees, I,- access., pumping (b) cleanout T-„� 001 c) lOr from cellar wall or in ground sZ-�-..-ng P (d) �5t from subsurface drall.ns Reg 10.2Distribution Bores (a) slope greater than 0.08 Reg 10.3 ( } sumo absurface Design Check Liat Page 2 FAIL CK Leaching Pits Leaching pits are preferred4ere the installation is possible 9g 11.2 a) calculations of leaching area-n!inimum 500 eq ft 11.4 b) spacing / i 11.10 c) surface drainage 2� 11.11 d) cover ma�tdaal e) 2'x2'x4p splash pad f) to"t elbow g) bends in pipe from d-box to pipe Leaching Fields N -g 15.1 no greater t an 20 n3.nutes/inch area-minimum 900 sq ft 15.4 construction of field 15.8 sarface drainage 2 % 3.7 e) 20' from cellar vall or inground sEu .ng pool Leachin Trenches gg 14.1 a) ca c ons'o `-leaching area-min 500 sq ft 14.3 1b) spa�cing;4ft min 6 ft with reserve between 14.4 c) di.mens�ions 14.6 d) ecotruction 14.7 @ 1h.10 surface drainage 2% ` Dow3hill Slop e a) slope y/x = (to be show) b) y/x X 150 = (to be shown) _ Punas g 9.1 a) approv } 9.6 b) s -by power ii 1