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Miscellaneous - 42 FULLER ROAD 4/30/2018 (2)
❑ o 4 rkt, �12 _ 1 i M I N, COVER_ IG LOT 15 ( IA ) FULLER RDaMI- TOP OF FND. No SLOPEo02 ' SEPTIC SYSTEM AS—BUILT 14 a57 ( 14_"Ib57) INV. 113. 42 ( 138.581._ Da BO X INLET f N V� rlNV. - —� H O'tJS E O�ITLET i �` Do BrJ X �U T 7 T v I -Q.02( 1,3 020) 7----- _ _ END OF PIPE/ r \ I iINV13 00( 13 X20) ExiSTIN6 DVV tiELLI G 23� tL2 \ \ - i\10 E (-,,) DEMO T ES DESIGN ELEV. AN K 0U T LE T VERT_ I„ 4L O„ SCALE, I „ HJP, 1Zo I = 40-0 �. \/� _� \ p I_ \/ s- 10 i i ti .= �,^ ..- I z i , L_rte,l— I ! � �'� �_� C ' T IC `� � 1 07 15 ( !A ) FULI_EP, RD NO ANDOVER. DATE I0-9-31 \ 'PR,ERll�, DED ICY FLY —_'�"t ALFRED !Z__._- ------ •------•--' - D 3-7C_\A I 1 v ri�`f 'SHAFA0 �R R Do ISTIE F L NOTE-,BENCH MARK= OP OF FNJr). LOT 15 ELE`v=i44a5! eC= o DATWO SEE PLAN; SY GELINAS A^•, D A5 OCo J0 3-2�-5 i DATE �` • S�gTLED • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF. COMPLIANCE As of: 7/1/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D-Box and outlet tee By: Todd Bateson At: 42 Fuller Road Map 065.0 Lot 0087 North Andover, MA 01845 //Tbf. Issuance of-At s ceiiificate shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant v Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com • SE Vjj • North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 42 Fuller Rd. MAP(%S-6 LOT: (,)0 fl INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box & outlet Tee INSPECTION: 7/1/14 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 ❑ Water tightness 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 -20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: • ,F °� Map-Block-Lot Commonwealth of Massachusetts • 065.00087 BOARD OF HEALTHPermit No------------ 3 North Andover BHP-2014-0678 I FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to(Repair)an Individual Sewage Disposal System. at No 42 FULLER ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2014-067 Dated June 25,2014 ---------------------- ----------------------------- Issued On:Jun-25-2014 ffiBt* ---------------- rCg�REALTH �,1� Ulu Y 42 FULLER ROAD Reference No: BHJ-2014-000043 ................................... Permit No: BHP-2014-0678 Department: ................................... North Andover BOARD OF HEALTH .--------------------------------------------------------------------------------------- Account No: 1001001.1.5.0510.00 FeeType: .................................... DWC-Component Repair PERMIT Receipt No: REC-2014-001696 ......................................................................................... ................................... Paid By: Paid in Full On: Wed Jun 25,2014 ToddBateson .................................... ------------------------------------------------....-----------------...---------------- Check No: 8160 Received By: .----------------------------------- Lisa Blackburn •........................................................................................ DEPARTMENT'S COPY Amount: $125.00 --------------------------------------------------------------------------------------------------------------------------------------------:::......:::::::::::::......... w = •. Application for Septic Disposal System TODAY'S DATE Construction Permit - TOWN OF $250.00—Full Repair NORTH ANDOVER, MA 01845 $125.00-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 ❑ Repair or replace an existing on-site sewage disposal system* _ only the tab key to move your 64kfepair or replace an existing system component—What? — o X .9— cursor-do not use the return A. Facility Information key. 411 �u!` - RECEIVED Address or Lot# raa I City/Town TOWN OF NORTH ANDOVER. ' 2.-*TYPE OF SEPW SYSTEM*: HEAD THS DEPARTMENT ➢ ❑ Pump ravity(choose one) ***If pump system, attach copy of electrical permit to application— ➢ onventional 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) ➢ ❑ Pressure Dosed(D-Box Pfresent)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information Name _ Address(if different from above) !� .a City/Town State Zip Code GI`s fob ro75`?/ Telephone Number 3. Installer Information Name Name of Co pPRISES,INC. 111 ARGILLA ROAD ANDOVER MA 01 RioAddress n A City/Town State ,r� Zip Code �7d 80/S-,; 703 Telephone Number(Cell Phone#if 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 - ° Application for Septic Disposal System V TODAY'S DATE Construction Permit - TOWN OF Y` $250.00—Full Repair NORTH ANDOVER, MA 01845 $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board o alth, the installed system is not approved. Name Date - p li ati n Approv y joarf Health Representative)t. 1 (0 ame Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached. Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump S sy tem? If so,Attach copy ofElectrical Permit Yes No 4. Reviewed approval letter, all paperwork received. Yes No M1sSl, 5. Foundation As-Built. (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 MrAV BLIGATIOM Aa the Anclo�ra.li ecl r die t�nstn 4ss" peptic cyst 'fecz.thepr p y ati pip (A44i s o epat tg:t=) ` " -For pl by t*tom to .appum*m of ( ►ea AM daed Diced WA> ons dated rased at) I gsndentand the folly obligations for rama9tment ofob ppiect: ,. I. is i$e iaMLUe4 I=' .ala�ted to cibtain.ail peaxs�iW and Board of Hetet Wrved phns to per $any:Work cm a sit-- ��hr-==41 a tat .-e t•4u zhen mtwd is . hslheia a.. ,I i*t-4#tt s�,►aQdatk3stapl�xiona: l£hom� cmtmctc4-projeetaawg,er,orany athsr,pen®a not 040ciftft—d my com�ay 01-du*ea imp caon and the sysicm is not=dy,thin Item&rw dWlbi,applicable. '1. ASi4. -j to.leave th. m� .: a pZfat to th;:Appii ie i P�As�s itdiciWl 114m., ce tris th5 mp a s is ret ag tel,v ich ah •bt dtiu t 'I ie ae r maw$a#Wpecdosl Ixpt �not have fm be prascsit• . b. for clevgtioaa,ties,etc'. A#la& o -Vesbtil Ole-(ar a •. QAA.,q from the emgi p&most be ttibsaiittcd toiae Bcgrd OfHealk sWarhi itiettc�, 5Van time. Itsatllier iriust bept6sesst for ?? pP stt r2ectcedotkauat be resdp ad able to :. •�tsae p�.��orlc aiid�m�o�.. • ` . . - -.. .• C. -anvil s mdc n vhf Ilp�tdina cap2o tte. WWlet docs snot 4. As-the iusullet'd utditiand&Ito*I p��thI.e '(#&FIbmr�,�des)aizd-I�•s�g*ed iD cot�#*m tl,6•i-ata k#0n.of the syster}�fdeat iso�itiett�e V xpplift iay�&M if8t t dou j r teas o;d rif t�+t s *aca g �� N North And=bbifi'caht imp t2 an tsarao�„_isa�bnl=1 tla�`, beeaf'Izle:'=' . 5. Iia t�exnat�llet,d er�aderdt t I muA'•hdudn-&*' 'thopzf c of tili€oll itsg comtmction. •aha: .. _. ,• : :_ _: ,. �: 11�tttt�rrartrs�ivs�r mat�$�p���evaefaa oftlie rxtr`asr�iss`her�re�cherat b. &Ttiift ofth d and*t v be mad . Q FAWAMPeadaff b,Boalf td` e�lit eafformogara � d .ta�mlta�to ofk,a? pYrst otoae, neat,primp cyber,fix •wall sad other . campaaea�. - • - - - �. � �it�3ffi tt. Lim, that I:: s�- Stiis6 for c i ffi ops n t teas a tier the ' ap ,s ! a>lsteri th r eta eantraceg ,err,ayj terse s si u satire ua�detsdcsd sera ,rust Clot Dgiml: -may y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Stephen Spicer Owner Owner's Name information is required for North Andover MA 01845 7/1/2014 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. ImpRECEMED Whennfilling out t: A. General Information forms on the computer,use 1. Inspector: only the tab key J'Jk H 2014 to move your Neil J. Bateson TOWN F T ANDOVER cursor-do not use the return Name of Inspector HEALTH DEPARTMENT key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI 15 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 ❑ Neqds Further Evaluation by the Local Approving Authority 7/1/2014 In oh Signa a 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 42 Fuller Road Property Address Stephen Spicer Owner Owner's Name information is North Andover MA 01845 7/1/2014 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: After permit from B.O.H., install new outlet tee with gas baffle in septic tank and new d-box with riser, 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-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ^ City/Town of System Pumping Record Form 4 DEP has provided this form for useby local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using-this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Locabo .9�Rig fron of h Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) Cityfrown ' State f Telephone Number3 B. Pumping Record 1. Date of Pumping 2. Quantityumpe DatePd: Gallons ' : 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Y" 9-60 If yes, was it cleaned? ❑ Yes ❑ No '5. Condition of,�;y�te'm�:��- ��� �'(A,4�-, � 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Lo contenta were disposed: Lowell Waste Water Sig HauleDate t5form4.doc•06!03 System Pumping Record•Page 1 of 1 i 42 FULLER ROAD - 2110/065._ a-0D87.0000.0 ) I r i J Commonwealth of Massachusetts Y Title 5 Official Inspection Form Iq Subsurface Sewage Disposal System Form Not for Voluntary Assessments I M 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection for�any way. Please see completeness checklist at the end of the form. t- U �� Important: A. General Information JUN 0 9 " When filling out forms on the computer,use 1Inspector: TOWN OF NORTH ANDOVER . only the tab key p HEALTH DEPARTMENT 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 gun Citylrown 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 ❑ Needs F rther aluation by the Local Approving Authority //1 1 t. 5/30/2014 Inspe o nature 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Citylrown 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: '13) System Conditionally Passes: Z 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . ' 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): 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•3/13 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 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. CityrFown 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. 3. Other: Outlet tee in septic tank, d-box&needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form V%IF Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•3113 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 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? 0 Yes 0 No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 1 year vacant Date 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? El 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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Pumped 2010, owner Source of information. Pum p 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 stem P P Y ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form: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 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 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: 33 years old, 10/9/1981, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.6 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.): 4" PVC through wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1.6 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 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: 3" t5ins•3/13 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 42 Fuller Road Property Address Steven Spicer Owner Owners Name information is required for North Andover MA 01845 5/30/2014 every page. Citylrown 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 N/A Scum thickness 3" Distance from top of scum to top of outlet tee or baffle N/A=Outlet tee off Distance from bottom of scum to bottom of outlet tee or baffle N/A 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 tee ok. Outlet tee corroded off. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3113 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 °rt 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is North Andover MA 01845 5/30/2014 required for every page. Cityrrown 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•3/13 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 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 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 badly corroded, has holes in side. Evidence of leakage&carryover. D-box needs to be replaced. 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City(rown 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 field 22'x 46' ❑ 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.): Soil ok.Vegetation ok. No sign of ponding to surface. Cesspools(cesspool must be ) ( plan): P as um ed art of inspection) locate on site P P ): Number and configuration Depth—to f liquid p p o quid to Inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Citylrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Til Inspection t e 5 0 ffi i t c aForm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 42 Fuller Road Property Address P Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown 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 Ar 67ccy' t) t 5-e_�4,i c, �JP/ nn t k7't4`' t5ins-3/13 Title 5 ficial Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 y i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >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: 5/31/1980 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: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 059 U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Fuller Road Property Address Steven Spicer Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown 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 t5ins-3/13 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Summary Record Card generated on 5/20/2014 12:09:44 PM by Maureen McAuley rage 1 Town of North Andover Tax Map # 210-065.0-0087-0000.0 Parcel Id 15311 42 FULLER ROAD SPICER, STEPHEN J. 42 FULLER ROAD N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zonirl 1 Residential Zonirl 1 Residential Size Total 1.06 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until SPICER,STEPHEN J. Payor 42 FULLER ROAD N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17214.0-42 FULLER ROAD Last Billing Date 4/2/2014 3160292 03 Cycle 03 Active UB Services Maint. Account No. 3160292 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE /1 UB Meter Maintenance Account No.3160292 Serial No Status Location Brand Type Size YTD Cons 32945247 a Active 00 b Badger w Water 0.63 0.63 453 Date Reading Code Consumption Posted Date Variance 3/7/2014 676 aActual 0 4/11/2014 -100% 12/5/2013 676 aActual 4 1/17/2014 -72% 9/6/2013 672 a Actual 14 10/15/2013 205% 6/10/2013 658 a Actual 5 7/24/2013 -42% 3/6/2013 653 a Actual 8 4/22/2013 -24% 12/7/2012 645 a Actual 11 1/9/2013 -81% 9/5/2012 634 a Actual 58 10/15/2012 1334% 6/6/2012 576 a Actual 4 7/16/2012 -100% 3/8/2012 572 a Actual 0 4/14/2012 -100% 12/5/2011 572 aActual 6 1/17/2012 -87% 9/7/2011- 566 a Actual 47 10/13/2011 4701% 6/6/2011 519 a Actual 1 7/20/2011 -82% 3/3/2011 518 a Actual 5 4/13/2011 -66% 12/6/2010 513 aActual 15 1/12/2011 -87% 9/7/2010 498 a Actual 127 10/15/2010 750% 6/3/2010 371 a Actual 14 7/15/2010 37% 3/5/2010 357 a Actual 10 4/14/2010 -36% 12/7/2009 347 aActual 17 1/12/2010 37% 9/3/2009 330 a Actual 12 10/15/2009 1% 6/3/2009 318 a Actual 11 7/20/2009 -4% 3/10/2009 307 a Actual 13 4/29/2009 12% 12/4/2008 294 aActual 11 1/20/2009 -75% 9/4/2008 283 a Actual 44 10/10/2008 169% 6/4/2008 239 a Actual 16 7/16/2008 24% Trouble Code:03 3/6/2008 223 aActual 13 4/11/2008 -50% 12/6/2007 210 aActual 24 1/22/2008 -69% 9/13/2007 186 a Actual 85 10/12/2007 568% 6/12/2007 101 a Actual 13 7/20/2007 -8% f, r 1 TOWN OFt� - SYSTEM PUMPING RECORD DATE: , SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) l C< Tu'Akf �d DATE OF PUMPING: O 5 QUANTITY PUMPED : 5 0 0 GALLONS CESSPOOL: 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: Bateson Enterprises, Inc. COMMENTS: r CONTENTS TRANSFERRED TO: i TOWN OF NORTH ANDOVER ,SYSTEM PUMPING RECORD y L;� 0� 9 ftv DATE: _ SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) RJ DATE OF PUMPING:-�-�_Q� QUANTITY PUMPED ( 0 C� GALLONS CESSPOOL: 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: U COMMENTS: CONTENTS TRANSFERRED TO: i I Address At -A-4 e P Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes. action Document/ document/ filum• Action Department Board of Appeals — Board of Health — Planniing Board — Conservation Commission — Building Department JCOmmonweal tIt of Massachusetts _ ! A1-A1-Z1A'-Massachusct(s System Pumping Record System Owner System Location Date of Pumping: o� � Quantity Pumped: gallons G Cesspool: No Yes L.) Septic Tank: No �_� Yes � ---- ! l System Pumped by: vctt`ejea 511&n,6 uaea License# i Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector TCS Ovt(}F E;�A . F Board of Health North AndoVr,Ma.ss Y SUBSURFACE DISPOSAL DESIGN cHEcK LIST LOT # ?PROVEDDATE ?✓3 /' - DISAPPROVED DATE rovideds i ons: itis V FAIL ag 2.5 jb, e submi e'd'p�anoustshow as a minimums the lot to be served-arealdimensions lot #,abutters location and log deep observation hoes-distance to ties location and results percolation tests-distance to ties design calculations & calculations showing required leaching area location and dimensions of system-including reserve area existing and proposed contours location any wet areas within 100, of sewage disposal system or disclaimer-check wetlands mapping surface and subsurface drains within loot of sewage disposal Sys tem or disclaimer (i) location any drainage easements td_thin .A01 of se$age disposal system or disclaimer-Planning- Board files �) knosn sources of water supply within 2001 of sevage disposal : system or disclainer (k) location of any proposed well to serve lot-100, from leaching facility ( location of water lines on property-]A, from leaching facility (m) location of benchmark n) driveways o garbage disposals (p) no PVC to be used in construction 7(q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans leg 6S tic Tanks a) capacities-150% of flow, water table, tees, depth of tees, access, pupping (b) cleanout C) lot from cellar `cal.1 or inground swimming pool d) 251 from subsurface drains :g 10.2. Distribution Boxes ( slope greater ME 0.08 :g 10.1 b) suite V� Sabmirface , si Check List Pae 2' FAIL OK Leaching Pits Leaching pits are referred where the installation is possible Reg 11.2 a} calculations of eaching area=minimum 500 eq ft 11..4 b) spacing 11.10 c surface a 2% 11.11 n cover mate al VxVAN lash pad ftee at w[,ge no ben in pipe from d-box to pipe Leaching Fields Reg 15.1 no greater than 20 mirrutes/inch b area-minimum 900 sg ft 15.4 c construction of field 15.8 surface drainage 2 % 3.7 a 202 from cellar wall or inground sing pool • i L!Ehing W ches Reg 14.1 acalculatioro eaChing area-min 500 sQ ft 14.3 b spacing- ft min 6 ft with reserve between 14.4 c dim:: ns 14.6 d) cons coon 14.7 e) sto e 14.10 f) su face drainage 2% Douihill Slope a pe-.*/-x = (to be shown b� y/x X 150 = (to be shown Puma Reg 9.1 a) rsd-by 9.6 b) power , i TOWN OF NO, TH ANDOVER ��1V � SYSTEM PUwiPING RECORD NOV 19 2004 DATE: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED 1500 GALLONS CESSPOOL: NO J 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: E V� C COMMENTS: CONTENTS TRANSFERRED TO: Board of Health SEPTIC SZSTEM 1 INSTA.ILA.TICN Ch-rK LIST LOT P QUID DnTE IlI F'rt 1 DATE -- XCAQATICH OK FAIL �_-- -- Rea *-r- sans FAITL OK 1. Distance TO! a. Wetlands b. Drains ` c. Well 1.00 2. Water Line Location 3• No PPC Pipe 4. Septic Tank=" a. _Tees -_Length & To Clean Out Covers _ b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cra(ks b. A11 Lines Flo,Ang Bqual Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth i-00 c. Capped Ends ' d. Clean Double Washed Stone t 7. Leach Pits a. Dimension b. Ston pth c. ash Pads Teas Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone / 8. No Garbage Disposal s 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location i4th Regard-to Pere Test d. Elevations e: Water Table IT I� ( i ) FULLER RD. _ �`,I IN� CQVEP,_ 12 LO A F LL OP OF FN D. aril No SLOP .02 SEPTIC SYSTEM AS—BUILT I " l- ( I!'.`0;, 7) INVo 13 4? 0380 )- i LD. BO X INLET _I_ti V-14 las INV lol—)lf-11/ N O'�S E 0 LET �� ! DaI�D�� X ' UTLET \, k END OF PIPE - O 1 !NA."o 140079(13 3 ) i Q EXISTIN CDWE I ` 20 j t 12 _ _ `� v NOTE (k.&>) DFN D ES DESIGN E FVo 4 TANK QU LE ; SCALE, VERT, I" 4 O„ G!,'\,'NERo )AYSGN REALTY PUS ,o�_ I , it LOCATION - LOT 15 ( 1A ) FULLER RD NO ANDOVER I \ -'PRER� RED __'Yo 0 AIL _ -- ALFRED DRAIN `,;t ►o'��'°i -T— I 1 - D Ro ' FU LLEP\ Nr:)TE;I:ENCN ,VARK = i c=' 0FN, - .� LOT 15 ELE`./= 4;tis-' US6G.S. ; DATUtis SEE PLAN LY GEL ' I`EAS AND ASSOC. , DATE D- 3-23— -A !,,I I-N, COVER 12 ' LOT 15 HA ) FULLER RD. TOP OF FND. �r�f Na SLOP Eo02 SEPTIC SYSTEfl AS—BUILT ' ' INV. 13 ,42 ( 13 85=' }- o_ ID. BOX INLET IN V� 141.52(I4QO3.) -- __ .� / INV. 139-32( 13&4— 1 ) -- � HC' ,jE OUTL FT \� i // D. H v=UTLcT INV 1 202( 1 ' END OF IPE 130T. 3FB-_D 40 O003 o2G) c �� —TNG TANK INLET` ' E X. I S 1 DWELLI1\I G 2 3 _ .\ O ( *12 INV 1406I ( I3°58),,-�- — 15 , O,NK OUTLET E (--&-) DENO_ ES DESIGN ELEV. SCALE VERTU I'= 4LO' OR i I �O-OJT - - gyp,, V ! I I� L1 S 11 — , 0Cr\ T ICS,— LOT 15 ( IA ) FULLER, RD NO ANDOVER DATE 10-9-151 PRERA RED I 'Yo d OF M, , o ! _ ----- -- ---- - - -- -- � y ALFREDDRAIN No �q� jf ', rC FU ��R RDo ,` '9FcrSF�aa��� I — 1 S 13 ; v., a fG�t 6 ; i NOTEsI�ENCH MARK TOP OF F[`.;;_/. LOT 15 ELEV= 4 ;-05 '' U cG o DATUiM SF_F PLAN (�Y GELINAS A,'D'D ASSOC;o DATEJO 3-23=? o FORM 4 - SYSTEM PLAUTNG RECOIW '; RSH ANOpVE�/ TOW BARD pF H�`tH t Commonwealth of Massachusetts NUV � 21995 Massachusetts Vste�ri Fu�rthi�te Record js em VIM Sysicrn Location E 61 611� Q G l��G Date of Pumping Q l!' �! u,antit%• Pumped: t Cesspool: No ,1�1 tie ❑ Sentir TAn E] Yes e� System Pumped by: V ' License #: Contents transferred to: Date Inspector i Commonwealth of Massachusetts Massachusetts mo stem f'umr�ing Record System OWnCr System Location � G �- "F Date of Pumping: G� ��� ?�2 Quahtity Puniped: C 51�U gallons Cesspool: No Yes U Septic Tank: No U Yes M' System Pumped by: FerecdOrt lo:rtL' l' wda License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: commonwealth of Massachusetts .E JJ Massachusetts stem PmmP ng Record Systetn Owner System Location V G� � - u Date of Pumping: Vl ^ ( � Quantity Pumped: (hal gallons Cesspool: No Yes U Septic Tank: No IJ Yes System Pumped by: Ver4eQoee License # Contents transferrred to : Greater Lawrence Sanitary District Pate: _ Inspector: n Commonwealth.of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When ruing out 1. System ocatio � forms computer, use use only the tab key Address to move yourL .t.---�U` cursor-do not City/Town use the°retum Sta a Zip Code key. 2. System Owner: Name ISI Address(if different from.iocation) Cityrrown State Telephone Number B. Pumping Record J 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 o If yes, was it cleaned? ❑ Yes`❑ No 5. Condition ofSyst�emQ: \rC 6. System Pu pe _.Name — Vehicle License Number Company . 7. Locatio a6re ontenf er IsPosed:: Signature of a e Date http://www.mass.gpv/dep/water/a provalt/t5forms htmi inspect t5forrn4.doc•06103 System Pumping Record•Page.1 of 1 i Commonwealth of Massachusetts RECEIVED City/Town of NOV 13 2008 a` System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location 9fron left rear, left side Euse Right front, right rear, right side of house. forms on the computer,use only the tab key Address L : _ ��_ , -.p to move your �� �L/� RkA�_� cursor-do not use the return City/Town State Zip Code key. 2 System Owner: n Name Address(if different from location) Citylrown State Zip CQ e Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: S Gallons 3. Type of system: Cesspool(s) eptic Tank El Tight Tank Other(describe): 4. Effluent Tee Filter present? Q Yes 1;i�o If yes, was it cleaned? Q Yes No 5. Condit�ion of System: !� 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati contents were disposed: .L.S.D Lowell Waste Water 62 igna ure of H u r Date t5form4.doc°06/03 System Pumping Record°Page 1 of 1 Commonwealth of Massachusetts City/Town of -w~ — System Pumping Record Form 4 NOV 2 2010 M 1 DEP has provided this form for use by local Boards of H fill Aaav sed, but the information must be,substantially the same as that provi e i #orm, check with your local Board of Health tQ determine the form they use. The ys em umping ecord must be submitted to the local Board of Health or-otter approving authority. A. Facility Information 1. System Location: Left side of house, Right side of hou , Left front of hou , Right front of house, Left rear of house, Right rear of house. Left rear of buil i rear of building. Address lU �S14 � Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town Stalp-) � ��,Zt'p Cade Telephone Number J B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [4-�o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syst © J 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca" ntents were disposed: G.L.S. Lo Waste Water Signature di fAupr Date t5form4.doc•06103 System Pumping Record•Page 1 of 1