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Miscellaneous - 417 RALEIGH TAVERN LANE 4/30/2018 (2)
` r417 RALEIGH IAVtKN LAN[ - — rr(�' 210/107.A-0095-0000.0 n Lane pORip 3r �SSACHU`�Et PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER �— SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( )constructed;( )repaired; h By: C mu D —6 (Print Name) Located at: 41-7 ZqLr_((qk4 _FAo4e Q_M L--� '� �'r�yr ✓t (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan,originally dated 3".t> lCIC" w b / and last revised on ,with a design flow of 6j r-, gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310.CMR 15.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan.All work is accurately represented on the As-built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: Engineer Representative(Signature) And—Print Name Final Construction Inspection Date: Engineer Representative(Signature) And—Print Name Installer: �`—l� (Signature) Date: nd—Print Name Enginer: (Signature) Date: �C°'tom C�l�oi.1 And—Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com As—Built Ties Note: This Plan illustrates Description A B as—built conditions of the 1. Tank(in) 24.7' 14.4' site as observed on 2. Tank(out) 32.0' 19.4' September 6, 2013. 3. D—Box 42.3' 24.8' #417 Raleigh Tavern Lane Bit. Conc. A Driveway Inv.-99.57 Covered Porch Inv.=99.11 0 10 1,500 Gal. BM 100.56 Cnr. v, Inv.= Monolithic Conc. (Assumed) 98.85 Septic Tank Inv.= 98.32 O Repaired 8' S of Perforated Approx._� Soil Leaching Pipe s AbsorptionPipes ----�� S 3 Approx. Soil Absorption Pipes s 9—Outlet s Inv.=98.14 D—Box App, Pro (Ave. Outlet) s --�_ ���iH ofSCOTT perty Line (Stone wall) + s CAMER F m C1 a7601 BM 100.00 Nail 0 5 1 0 20 in Tree (Assumed) THE NEVE-MORIN GROUP, INC. TANK & D-BOX 447 Boston Street, US Route I, Topsfield, MA 01983 AS-BUILT SKETCH p 1978-887.8586 f 1978.887.3480 www.nevemorin.com 417 RALEIGH TAVERN LN Date: September 9, 2013TScale: I"=10' No. ANDOVER, MA loft Note: This Plan has been Prepared to Replace an f''}} OF Existing Septic Tank and Distribution Box. r, 6Y ;1 #417 Raleigh Tavern Lan ' Pump, Crush & Backfill Bit. Conc. Driveway Exist. Tank in Accordance With 310 CMR 15.354 O00 p Inv.=99.93XI N O _O f �• 99.7 To Tank Prop. 18 LF 4" PVC Covered Porch p (Sch.40) Pipe 00.8FG S=0.048 New 1,500 Gal Septic Tank 5Afin. Inv.(In)=99.07 BM 100.56 Cnr. O Inv.(Out)=98.82 P&OV . Conc. (Assumed) &""' b g As Sys. 0 °x Soil gbsor s O� 8�, 0 LF 4" PVC;j� o s bion Pipes � (Sch.40) Pipe Q pb0 ----_ s s s S=0.02 s _�s s New 9—Outlet D—Box (Connect AAProx Pro �� s `� to Exist. Field perty LineLaterals) (Stone wall) Inv.(In)=98.62 Inv.(Out)=98.45 BM 100.00 Nail 0 5 10 20 in Tree (Assumed) THE NEVE-MORIN GROUP, INC. TANK & D-BOX 447 Boston Street, US Route I, Topsfield, MA 01983 REPAIR SKETCH p 1978.887.8586 f 1978.887.3480 vvww.nevemorin.com 417 RALEIGH TAVERN LN Date: August 13, 2013 Scale: I "=10' N0. ANDOVER, MA I of 3 1 ./1� L ��o�� '�$ � d � �� .. o � a�� ..�. 1 � . Commonwealth of Massachusettsu ' W City/Town of No Andover System Pumping Record OCT 07 2013 Form 4 TOWN OF NORTH ANDOVER �N 5 HEALTH DEPARTMr--h�r DEP has provided this form for use by local Boards of Health. Other fo ms�nay,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 L To on the computer, use only the tab �j I ation:�6' !Itn Very L-an key to move your Address cursor-do not No Andover use the return key. City(rown State _ Zip Code t�I1 2. System Owner: Name reRm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDate 2. Quantity Pumped: Gallo 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were dis d: Stewart's Pre-tr en t So. ill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 QF '` • � A North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 417 Raleigh Tavern Lane MAP: 107A LOT: 0095 INSTALLER: Blake Seale DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 9/5/13 (D-Box also) 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 .1 ❑ 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 F-11 '00 gallon Pump Chamber installed ❑ H-1b loading ❑ Monoljthic tank construction ❑ Inlet to installed, centered under access port ❑ Pump(s) 'stalled on stable base ❑ Alarm float"working ❑ Pump On/01loats working ❑ Separate on/o \�floats ❑ Drain hole in pressure line ❑ cover at finI grade installed over pump access port El Water tightness of tan has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ AI��& Pump are on separate circuits E] Alarm sou�ds when float is tripped ❑ Location of coNrol panel: basement F1 Alarm signal locat�d.inside: basement Comments: DISTRIBUTION-BOX R Installed on stable stone base 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: 4-5 -1 wr 14- VvvS tom® [ tea✓ v� G� �`-C-�j' r-cP�,vU� /1 Note: This Plan has been A 'PFFGVED BY Prepared to Replace anje.11 �J1� �a`A�m�'L! Existing Septic Tank and �l Distribution Box. #417 Raleigh Tavern Lar&, Pump, Crush & Backfill Bit. Conc. Driveway Exist. Tank in Accordance With 310 CMR 15.354 QQ�O � Q' Inv.=99.93 N O _O 99.7 To T Prop. 18 LF 4" PVC Covered Porch p Tank (Sch.40) Pipe S 00.8FG =0.048 Cn o New 1,500 Gal C Septic Tank 5�y • Inv.(In)=99.07 BM 100.56 Cnr. O Inv.(Out)=98.82 Conc. (Assumed) P Soil Abs---.— 0� 8 Prop. 10 LF 4" PVC S —�Poon Pipes F� (Sch.40) Pipe �-� s s s ��� s S=0.02 New 9—Outlet S s��� D—Box (Connect ApproxPro Y to Exist. Field pert _i Laterals) Line (Stone + Wall) Inv.(ln)=98.62 Inv.(Out)=98.45 BM 100.00 Nail 0 5 10 20 in Tree (Assumed) THE NEVE-MORIN GROUP, INC. TANK & D-BOX 447 Boston Street, US Route 1, Topsfield, MA 01983 REPAIR SKETCH p 1978.887.8586 f 1978.887.3480 wvvw.nevemorin.com 417 RALEIGH TAVERN LN Date: August 13, 2013 Scale: I "=I o' No. ANDOVER, MA I of 3 i 132' 20'4 Cleanout Cover 3 Places Plan View Max. 9'of Cover 3'Vent Over Tank(Typ.) 4' OuRutbrt800t with Clamp 3'Vent 4'0 Outlet ,o Rubber Boot ;., io with Clamp o � Liq�L,,O ` +• Outlet Tee LO to vn Inlet Tee Gas Baffl • 4' ap Plugall Weephdes with Non—Shrink Mortar 6'Base of 3/4' — 1 1/2'Gushed Stone trtar EIGHT ITEM NO. TK—M15OO20H HO 13,320! Notes: Section View 1. Concrete 4,000 PSI minimum after 28 days. 2. Design conforms with 310 CMR 15.00, DEP Title 5 regulations for septic tanks 3. All reinforcement per ASTM C1227. 4. Baffle wall required. 5. Tees and gas baffle required. 6. Tongue and groove Joint sealed with butyl resin. THE NEVE-MORIN GROUP, INC. 1 ,500 GALLON 447 Boston Street, US Route 1, Topsfield, MA 01983 SEPTIC TANK DETAIL p 1978.887.8586 f 1978.887.3480 www.nevemorin.com 417 RALEIGH TAVERN LN Date: August 13, 2013Scale: N.T.S. No. ANDOVER, MA 2of3 .. .. V 29" I I N 9 1/2 0.C. Plan View (1) 4" DIA INLET .O O 0 .,�$) 4,� DIA OUTLET : PLASTIC PIPE SEAL N N •- O 7. N 2" V 6" Base of 3/4" — 1 1/2" Crushed Stone Section View Notes: 1. Install flow equalizers. 2. Concrete 4,000 PSI Min. after 28 days. 3. Design shall conform with 310 CMR 15.00, DEP Title 5 Regulations for distribution boxes. WEIGHT ITEM NO. B-8DB W/COVER 514# THE NEVE-MORIN GROUP, INC. 447 Boston Street, US Route I, Topsfield, MA 01983 D-BOX DETAIL p 1978.887.8586 f 1978.887.3480 417 RALEIGH TAVERN LN www.nevemorin.com - No. ANDOVER, MA Date: August 13, 2013 Scale: N.T.S. 3 of 3 I Blackburn, Lisa From: Sawyer, Susan Sent: Thursday, August 29, 2013 2:41 PM To: Scott Cameron Cc: Blackburn, Lisa Subject: RE:417 Raleigh Tavern Great.Thanks Scott. Susan From: Scott Cameron [mailto:scottCd)nevemorin.com] Sent: Thursday, August 29, 2013 1:21 PM To: Sawyer, Susan Subject: 417 Raleigh Tavern Susan: Thanks for following up. The sketch plan that Mrs. Shurtleff sent to you is the correct plan for your files and for the installer to work from. I'm not sure on the schedule but the installer will take care of the permit when they are ready for the work. Please let me know if you have any questions. Respectfully, Scott P. Cameron, P.E. THE NEVE-MORIN GROUP, INC.447 Boston Street, US Route 1,Topsfield, MA 01983 p 1978.887.8586 m 1781.520.9496 f 1978.887.3480 w (www.nevemorin.com Please consider the environment before printing this email! Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. i� 1• 417 Raleigh Tavern Lane Notes by Susan Sawyer August 7, 2013 Received request to install a tank and distribution box at this property.A passing Title V had been submitted in 2012, however a buyer had requested that they have an another opinion.This opinion found that the tank was compromised;the knock outs were not present and the tank was leaking. It is 39 year old. Replacement was recommended.Also the D-box was deteriorated; also recommended replacement. S.Sawyer spoke with the engineer;to approve a disposal works permit,the health department would need a plan showing the location of the new tank(changing from 1000 to 1500)and new elevations and the new d-box.Then the engineer will do an as-built after overseeing the installation. The homeowner called me and I confirmed that this was what we needed. I had to have something for the installer to work off of and I need an as in ground plan for the file for future. I also advised her and her engineer,that before installation the owner should consider whether there are any future plans to expand the deck or do anything that would require the tank to be relocated.This would be wise, so not to have to address it at a later date. sl z 813 4-P �,.,`i s .�..�—E-- r^ .mac_c� ✓ � � 2�---�,/V 1�.�—�S . J`� �'t.c. �S )D)P I 4_- ►Com+-^L5 '� C- t`S a Cf NORTH, 6578 A.o ,SMO A o_ 9 Town of North Andover HEALTH DEPARTMENT ,SSACNUSt4 CHECK#: ()931DATE: 13113 LOCATION: H/O NAME: 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 $'�K � Septic Disposal Works Construction(DWC) $V. ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer f NORY1�, 6578 00 9 Town of North Andover HEALTH DEPARTMENT CHECK#: C7` DATE: t LOCATION: 0 t H/O NAME:- 5h V _4 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 $ V Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Vj Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer • Map-Block-Lot 5,t,-ren ,' , Commonwealth of Massachusetts • 107.A0095 ^� p BOARD OF HEALTH • ,�,,,= Permit No - - North Andover BHP-2013-08-81 ------------ -- -- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Blake Seale ---------------------------------- --------------------------------------- to(Repair)an Individual Sewage Disposal System.���'�� OPY P ! � at No RL -4-1-7-RALEIGH--TAVERN----------------- ANE -------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2013-088 Dated August 29,2013 ----------------------------------------------------------------- Issued On:Aug-30-2013 BOARD OF HEALTH CM U6-P-A 6)� b Application for Septic Disposal System Construction Permit- TOWN OF ro�AYsDATE NORTH ANDOVER, MA 0184 $25 oo-Component 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 gepair air or replace an existing on-site sewage disposal system.* only the tab key to move your or replace an existing system component—What?S !A to cursor-do not usekey.the return A. Facility Information Ad ss or Lot# 1791). i ... Cirylfown 2.-*TYPE OF SEPTIC SYSTEM*: 1 ❑Pump ❑ Gravity(choose one) ,rye ***If pump system.attach copy of electrical permit to application*** Z<"onventlonal System(pipe and stone system) „ ❑ infiltrator or Siodiffuser(Gravel-Less)jAttach a copy of your certification to install this type of system.Q, ) �--� ❑ Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed(D-Box Present)S.A.S. (y 2. Owner Information Ip"v I�� r av"7 ,� S/) V ,p Address(if different from above) City/Town sst�taatjte �A1 Zip Code T9Te�ioYe Number , 3, Installer Information 8m6neName of Company City/Town �Q ��� /well stateZipZip Code Teleph6n Num9(%n Ph tf possible please} 4. Designer Information Name Name of Company Cily/Tuwn�j�g '„[/ Shale /''� "� Zip Code - tt�� Telephone Number(Best#to Reach) f7e 8 0i 7i FST'6 Application for Disposal eystelm Construction Permit•Page 1 of 2 Application for Septic Disposal System Construction Permit— TOWN OF TODAY'S DATE NORTH ANDOVER. KA, 01845 250.00-Full Repair $125.00-Component PAGE 2 OF 2 A. Facility Information continued.... S. Type of Building: [Wesidential Dwelling or❑Commercial S. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with rhe provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certtfkate of Compliance has been Issued by this Board of Health. Name Date Application pproved By:(Board ofHeatth Representative)` Name Date r/�.q l t -- ((( 7p1i tion Disap ed rt sfollowing reasons: For Office Use only: 1. Fee Attached.= I es` No Projec t.11anager Ob]46,atr'on Form Attached,- 3'es� No J. PaL).7 rstern li*so, Attach cQL7 r o.fElectricrl Permit I esr A70 4. Fotu)cladan As-Built.- mew construction ronlyj; 3"es_� �o /v�ru)r�rrdr as,j�l�ru�rdl,l�rr)% . Floor Plans. mew construction onty j; li�o Application for Disposal System construction Permit•Page 2 of 2 TOWN OF NORTH ANDOVER Permit Number NORTH ANDOVER,MASSACHUSETTS 01845 Date Issued Expiration Date Jackie"s Law -- permit Application Pursuant to G.L. c. 82A §l and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of App1idurt/3`4*,, T. Seq 1,,o Phone Cell srr �ddre 97? Citylfown MA I ZIP 019- 5 Name ofExcavator(f different from lit) phone CeB S crown MA ziP N of OwneT)VProT� Phone Cell T 60 Street Address CityTow/n MA ZIP Other Contac Permit Fee Received N Y Description,location and purpose of proposed trench: Please desenle the exact location of the proposed trench and its purpose(include a mon of what is(or is intended)to be laid in proposed trench(eg;pipedeable lines.etc-)Please use reverse side if additional space is needed. 0/ Insurance Certificate#: �� Name and Contact Information of Inaarer. . �� (o"►v`jS�s, • C PoliExpiration Date: � Dig Safe#: Name of Competent Person(as defined by 520 CMR 7.02): Massachusetts Hoisting Iken"# License Grade: )9 1E Date:J/ c,?®/� BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.e.92A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE EXCAVA OR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNA DIFFERENT) DATE: 21Page CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.92A AND 520 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following: i. No trench may,be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); ii. Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR 1926.650 et.seq.,entitled Subpart P"Excavations". iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety; (2)that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CMR 1926.650 et.seq.,entitled Subpart P`Excavations"as well as any other excavation requirements established by this municipality;and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www,rnass.eov/dns 6219 4 F FG Town of North Andover HEALTH DEPARTMENT S�CHUS! CHECK#: (o 3 DATE: 1 ) 2 LOCATION: 1`2 Q0 1 P i nh -7—n k-,rr r- r_ `- H/O NAME: CONTRACTOR NAME: y 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 $ ❑ TrasIVSolid 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) $ HeaftAg t Initials White-Applicant Yellow-Health Pink-Treasurer � ��TtiED 16y' BILE COPY F PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF. COMPLIANCE As of: 9/6/2013 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Septic Tank and D-Box By: Blake Seale At: 417 Raleigh Tavern Lane Map 107A Lot 0095 North Andover, MA 01845 The Iss ce of this certificate shall not be construed as a guarantee that the system will function satisfactorily. san Sa er Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 1 r 6204 s Town of North Andover `�'•,,,,..: HEALTH DEPARTMENT emustt CHECK#: %� DATE: LOCATION: H/O NAME: 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) $ ❑ Tftl 5Inspector $ ZTitle 5 Report ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer J111 � l Fas# RECD V _ Ju X30, 2012 TOWN OF NORTH ANDOVER Y IV SPEC 110 HEALTH DEPARTMENT Dean G.Luscomb II&Sons P.O.Box 135 Middleton,MA 01949 978-774-4065 Licensed Plumber#20285 x hh1 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM V PROPERTY OWNERS NAMB-D m 7LZC Oy_k-l-, PROPERTY ADDRESS G� V r d ADDRESS OF OWNER(i€diff=d) -aame DATE OF INSPECTIO Q 1 NAME OF INSPECTOR QUALITY IS NUMBER ONE TO US. I' Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 417 Raleigh Tavern Lane Property Address Dmitdy Zolotykh Owner Owner's Name information is required for North Andover MA 01845 July 17, 2012 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 RECis,V'IIN forms on the computer,use 1. Inspector: JUL 3 Q 2012 only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector TOWN OF NORTH AND0vtK use the return p HEALTH DEPARTMENT key. Dean G. Luscomb II &Sons Company Name P.O. Box 135 Com Address Company Middleton MA 01949 City/Town State Zip Code 978-774-4065 S1848 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: i ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority July 17 2012 Inspictors 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•11/10 Title 5 Official Inspection Foam: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 w 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is Y 17 2012 North Andover MA 01845 Jul required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Checl Aj ,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 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 417 Raleigh Tavern Lane M Property Address Dmitriy Zolotykh Owner Owner's Name information is required for North Andover MA 01845 July 17, 2012 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ 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): u C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 Title 5 Official Inspection 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 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is required for Northover y AndMA 01845 Jul 17 2012 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". 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. V 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 El ® 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts OF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 417 Raleigh Tavern Lane dd r Property Address Dmitriy ZolQtykh Owner Owner's Name information is North Andover MA 01845 July 17, 2012 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ''11 Yes No V ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: r ❑ ® 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 f design flow of 10,000 gpd to 15,000 gpd. i For large systems, you must indicate either"yes"or"no"to each of the following, in additio -to the U questionsimSection D. Yes No ❑ ❑ the system is 400 feet of a surface ' ing water supply ❑ ❑ the system is within 200 fe f Ibutary to a surface drinking water supply 11 El Area system is located ' nitrogen sitive area (Interim Wellhead Protection Area—IWPA)or apped Zone II of a lic water supply well If you have answered"yes"to y question in Section E the system is comidered a significant threat, or answered "yes" in Sec' D above the large system has failed. The owner o erator of any large system considered gnificant threat under Section E or failed under Section D sha4upgradp,the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 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 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is North Andover MA 01845 July 17 2012 required for , every page. City/Town 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is North Andover MA 01845 July 17, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Owner 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 ears usage d town water 9 ( Y 9 (gp ))� Detail: 1 ( 2- Sump ( ZSump pump? ® Yes ❑ No Last date of occupancy: Current Date Comftterc al/Industrial Flow Conditions: Type of Establishmen : Design flow(based on 310 CMR 15. Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pres ❑ Yes ❑ No Non-sanitary waste d' arged to the Title 5 system? Yes ❑ No Water m readings, if available: t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form m _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is required for Northover y AndMA 01845 Jul 17 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of oc Qy/use: Date -" Other(describe below): General Information Pumping Records: Source of information: Last pumped 5 years ago-2007 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: No need at this time 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): I t5ins•11/10 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 417 Raleigh Tavern Lane ,p Property Address Dmitriy Zolotykh Owner Owner's Name information is required for North Andover MA 01845 July 17, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: System was installed in 1974-38 years old-owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ 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.): Main line and joints are in good condition with no signs of any problems. Septic Tank(locate on site plan): 6,. Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular concrete 1000 gallons If n is metal, list age: ears on Irmed by a Certificate of Compliance?(attach a copy of certificate) s-B--PIe 5' Dx5'Wx8' L el Dimensions: Sludge depth: 1" t5ins•11/10 Title 5 Official 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 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is required for Northover y AndMA 01845 Jul 17, 2012 every page. Cityrrown 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 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? sticks and 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.): The septic tank and baffles are in very good condition. The solids in the tank are very light. The liquid in the tank is running at it's correct working heigth. The tank does not require pumping at this time. Grease Trap(locate on site plan): Depth below grade: feet Material of constru ' n: El concrete El meta El fiberglass ❑ polyethyle ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to of outlet tee or baffle Distance from botto of scum to bottom of outlet tee or baffle Date of 1,11 umping: Date t5ins•11110 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 Form -Not for Voluntary Assessments 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is required for North Andover MA 01845 July 17 2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, Iiquid.Jevels 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 ❑o er(explain): , Dimensions: Capacity: `� gallons Design Flow: �� g -. II n r da ga o s'pe y Alarm present: Yes ❑ No Alarm level: Alar in working order: ❑ Yes ❑ No Date of last pumping: Date XdfloatComments(condition ofhes, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No in 11110 t5 s• Title 5 Oficial 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 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is required for North Andover MA 01845 July 17, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) L Distribution Box(if present must be opened) (locate on site plan): / Depth of liquid level above outlet invert Zero" 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.): The d-box is 12"below grade and is 20"x 20"square. The d-box is level with an even distribution. The soil in this area is clean and dry with no signs of any problems. The liquid in the d-box is running at it's correct working heigth. Pump Chamber(locate on site plan): V Pumps in working order: ❑ Yes No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber�;i�tionofp and appurtenances, etc.): L Soil Absorption System(SAS) (locate on site plan, excavation not required): 7 If SAS not located, explain why: S.A.S.was located by d-box and level area of yard. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is required for North Andover MA 01845 July 17, 2012 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 fields number, dimensions: 1 -20'x40 ❑ 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.): The S.A.S. is in very good condition with no signs of any problems. The soil in this area is clean with no signs of ponding or breakout. This area is covered with well maintained green grass. ools (cesspool must be pumped as part of inspection) (locate on site plan): Number and con ation — Depth to of liquid to inlet in P P q Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of cows ruction Indicat(on of groundwater inflow ❑ Yes ❑ t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'' 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is u North Andover MA 01845 July required for _ Y 17 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments to c diol etc.): tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, ry (locate on site plan): Materials of con tion: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic fail f ponding, condition of vegetation, etc.): ' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is North Andover MA 01845 July 17, 2012 required for everypage. City/Town State Zip Code Date of Inspection D. System Informaflon (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 r gat i5ijl�Taven fn, A Wove'ftl C� P vie, k5Oco �7 _ A o�G., ,C�o / o ° V4- 1/0 J I t5ins•11/10 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 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owner's Name information is North Andover MA 01845 July 17, 2012 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar S"'p ro"'^"P ® Shallow wells tNti`tit� Estimated depth to high ground water: 5'+/- below grade 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: No records on file. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The basement is 5' below grade with a sump pump in it. The propertyto the far side, drops off P steadily 5' +with no water. Rowley Tavern Road drops off sharply away from the property. The SAS is no deeper than 30" below grade, as the d-box is 12"below grade. 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 17 P7 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 417 Raleigh Tavern Lane Property Address Dmitriy Zolotykh Owner Owners Name information is required for North Andover MA 01845 July 17, 2012 every page. Cityrrown 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated cn 7/18/2012 2'33'.31 PM by Maureen McAuiey 1+ ` Page 1 Town of North Andover Tax Map # 210-107.A-0095-0000.0 is Parcel Id 17920 417 RALEIGH TAVERN LANE ZOLOTYKH, VALERIY&TATYANA 417 RALEIGH TAVERN LANE N. ANDOVER, MA x 01845 Class 101 Single Family Property Type Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres 1 Residential FY 2013 UB Mailing Index Name/Address Type Loan Number Activellnact. From ZOLOTYKH,VALERIY&TATYANA Payor Until 417 RALEIGH TAVERN LANE N.ANDOVER,MA 01845 i UB Account Maint 1 Account No Cycle Occupant Name Activellnactive Bldg Id:14119.0-417 RALEIGH TAVERN LANE Last Billing Date 6/15/2012 2100100 02 Cycle 02 Active UB Services.Maint Account No.2100100 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No.2100100 Serial No Status Location Brand T 32945545 a Active ERT HH b Badger Pe Size YTD Cons Water 0.63 0.63 Date Reading Code Consumption Posted Date239 5/2/2012 380 a Actual 15 6/20/2012 Varianc 2/212012 365 a Actual 15 3/14/2012 3% 11/1/2011 350 a Actual 16 12/152011 -7% 8/1/201.1 334 a Actual 18 9/14/2011 -12% 5/2/2011 316 a Actual 19 6/13/2011 -9% 2142011 297 a Actual 21 3/15/2011 .1% 1.1/112010 276 a Actual 15 12/132010 34% 8/2/2010 261 a Actual -6% 5132010 245. a Actual 16 6/9/2010 0% 2/1/2010 229 a Actual i 14% 0 0 f 122009 215 a Actual 3/11200uai 10 12!112009 4000 8132009 205 a Actual 14 9/11/2009 -30% 5/6/2009 191 a Actual 12 6/16/2009 1'9% 2/4/2009 179 a Actual 11 3/16/2009 11°!° 11/3/2008 168 a Actual 14 12/102008 -21% 8/1/2008 154 a Actual 13 9/122008 5% 5/12008 141. a Actual 11 6/18/2008 12% 2/4/2008 130 a Actual 16 3/142008 -25% 11/1/2007 114 a Actual 18 1/152008 -16% 8/32007 96 a Actual 16 9/142007 15% 5/3/2007 80 a Actual 12 6/26/2007 3% 2212007 68 a Actual 24 3/23/2007 -21% 11/12006 44 aActual 1 8 10% 12/222006 8112 -21006 26 a Actual 22 9/13/2006 5/4/2006 4 a Actual 4 620/2006 85% 4!4/2006 0 n New Meter -100%0 6120/2006 4/4/2006 4314 r Replacement 9 6/202006 -100% 202006 4305 a Actual 15 3/132006 -9% MSG ACTUAL SAYS 3D5 -21% 11/12005 4290 a Actual 17 12/142005 6% COAiliONVVEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Comnussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Iq j� 00 V e a— PART A !T CERTIFICATION V cv�L jq �� Property Address: P fS k ����Name of Owner �7 9 4 Py 0U Address of Owner: S,4�, Date of inspection: Name of Inspector:(Please Print) S J LU (30 .4 1 am a DEP approved system inspector pursuant to Section 15. of Title 5 1310 CMR 15.000) Cly Name: fwa v t + P1 D h U t'✓ ! t4l,J /C. Mailing Address: t/") 2.ra I t(t.v Yds Sr Telephone Number: —T—�L/�u�✓ r l I /. 1V11a - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails �!2 Inspector's Signature: Date: ci The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS -A ati• .r :� i f ' revised 9/2/98 Paget of 11 �: Printed or Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)) 'roperty Address: p/7 Jwner: Date of Inspection: l c�PK -e K —?J--0 0 INSPECTION SUMMARY: Check A, B, C, or D: ✓ A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no,or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of114 „ •� .. ,'..,... .� � `... x a._, - "' .-.�..�� �.. a ,.—_ .._ _ i .. .. f• j� r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ,�I? ��li�r l9•� !�,�tID✓✓j �"� ` Owner: Date of Inspection: C. (FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the T public health,safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used.to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: l Owner: Date of Inspection: D. SYSTEM FAILS: st aindicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this Yoy determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: Ald- The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B A4,1 CHECKLIST Property Address: )-// 7/ Owner: )'T / 7 — Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / [15.302(3)(b)) _ _ The facility owner (and occupants,if different from owner) were provided with information on the proper.maintenanc8..of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C IA, SYSTEM INFORMATION 'roperty Address: i_/� ,2 f l_P/Gf� /!"� afl�4-j /d 141, Owner: /� v Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual):_ Total DESIGN flow "01 Number of current residents: // v.TF4 \ Garbage grinder(yes or no): �c (/yvT 1 Laundry(separate system) (yes lor no) ; If yes, separate.inspection required Laundry system inspected (yes or no) ' Seasonal use (yes or no):—,�/6 Water meter readings,if available (last two year's usage(gpd►: Sump Pump(yes or no):—j-/0 Last date of occupancy: �+�ur7r COMMERCIAL/INDUSTRIAL: RAI I Type of establishment: fly► Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: VP 1 t,,- 4 System pumped as part of inspection: lyes or no)_ If yes, volume pumped: gallons Reason for pumping: P eye Tft Aaie' TYPE OF STEM 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed Jif known)and source of information: .0 I G / 7k Sewage odors detected when arriving at the site: lyes or no) revised 9/2/98 Page t�rll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: J� ,t G ��f�j /ic./ .✓ . Owner: /7 Date of Inspection: 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 Diameter Cf I Comments:(condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site pln) r{ Depth below grade: Material of construction:_"'concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: r/ r Distance from top ofJudge to bottom of outlet tee or baffle: hickness: j Scum t ( �° Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 1 ooiz / TZ) © U I—Z-4P GREASE TRAP: ' (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal Fiberglass _Polyethylene,_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc. revised 9/2/98 Page 7ofII F ,Y. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) 'roperty Address: /1L ���� `7 Jwner: �9 Date of Inspection: ,/ SOIL ABSORPTION SYSTEM(SAS): J (locate on site plan,if possible; exca � not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length:�—� leaching fields, number, dimensions: C1C� L///mss overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) �//� S/�� �� /",� y�[J�j /ac.cer ,/c"A/[ �J�2xp L�►/ � D'•�-ln��L[�.-, CESSPOOLS:_ (locate on site plan) �(e ANumber and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of 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.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .ySYSTEM INFORMATION Icontirwed) 'roperty Address: �v°r � �� Owner: J/ �✓�"'l'G-v Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ ►f�f} Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:,V�% (locate on site plan) Depth of liquid level above outlet invert:-� J Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) U tS l� C Ga r t� ,ul / T/a A Alli 4'V1/9'-4" e- PUMP CHAMBER:—k/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 1W R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ( � 7 p��� SYSTEM INFORMATION(continued) Noperty Address: /1 � Jwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 5 y i t 4 i 5 13 revised 9/2/98 page 10oth s. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // A_ •7�� �`,/ SYSTEM INFORMATION(continued) operty Address: jwner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells �� Estimated Depth to Groundwater_Feet Please indicate all the methods used to determine High Groundwater Elevation: (✓' Obtained from Design Plans on record (Observed Site(Abutting property, observation hole, basement sump etc.) +r Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page ttofII f j I TOWN OF NORTH ANDOVER 0711- SYSTEM PUMPING RECORD__ DATE: / ca SYSTEM OWNER & ADDRESS SYSTEM LOCATION zw/ul& (example: left front of house) -///7 / � c � Allt DATE OF PUMPING: QUANTITY PUMPED 050 GALLONS CESSPOOL: NO L'-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) I SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: r}'1 ✓ �/(� i Commonwealth of Massachusetts RECEIVED Rowley, Massachusetts ` stem Pumping Record MAR = 2 2005 VER System Owner System Location HEALTH DEPARTMEN I Wit-- �v0A &t�v, Type: Emergency 0 Routine Cesspool: No 0 Yes 0 Septic Tank: No 0 Yes�( Date of Pumping / 0,3j Quantity Pumped 1 gallons i System Pumped by(Company) Permit # Contents transferred to: 60, t'• Contents disposed at: F Date !�j`Pumper Signature Condition of system/other comments: 71(2 v f T- r nN J.t..5! k� 771�y r'bit +pry a�.w.4 �.�.d�s '7b'a av�i�"'r o o+ •9d��1 :t+�i),,?! CS s•i V�It}' fj-A- c7c�^jx f t_ T - - - - _ `7brtJ�'rJt+*rZfC1u t -5 Z d` wds ON ONS Oa c: I �W o 1S3N83 C.,6 vw 1 �3'�'`e-�N y 1Id 1 F p � +� � /� ��� .., ✓Q� '-•�•-^ � �• N _ '�Vit--�t arASNE/.�' 7e.v� J ,} / r� b G • V � • ',$•SZ �4wL'�t2 afaGt3�stbC� $ 1{'+c t-c>Igm93-£2 i ` f ��• � 11 y pygq�� y /.— .�. •fi, t .7��f� { i Lc fSY i1 r! q fl, P. [? � n � � ,, .'acv ._ �► �t is �. C7"� ZS Citi,, iLEo`1ov� -rap �a��, t. � 4+K•i�E`"`� I I hltEA.ILS pCAJC C w r ti G aqui EL ! 1 APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I here y make a plication for a permit for a sewage disposal installation at Z � I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, .the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of / — in size. . A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 1 lineal (square) feet of effective absorption area. The pipes will be laid' on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be s,�gbmatted with application. DATE //-/ -7 gnature of Applican I hereby issue the above permit for the Board of Health of the Town of North Andover,,Massachusetts. DATE j/ / /- -1 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. a DATE Signature of Inspecting Officer Percolation Test 19 5, C Garbage Grinder