HomeMy WebLinkAboutMiscellaneous - 44 BRIDGES LANE 4/30/2018 J44 BRIDGES LANE 1
210/104.D-0073-0000.0 -
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CONSTRUCTION APPROVAL
Has plan review fee been paid: <:Z_D NO Permit# 9��
Plan Approval: Date: Approved by:
Designer: Plan Date:
Conditions: 7-,el,--
Water Supply: Town Well
Well Permit: '` Driller:
Well Tests: Chemical �'� Date Approved
Bacteria I Date Approved
Bacteria II Date Approved
Plumbing Sign-Off: Wiring Sign.-Off:
Comments:
Form"U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? NO '
Well Construction Approval? YES NO
Septic System Construction Approval? c--ft__SD NO
Certification? YES NO
Other YES NO
Any Variance Needed? Qig NO
FINAL BOARD OJ' $EALTH APPROVAL:
DATE: %'Z511Q
APPROVED BY:
SEPTIC SYSTEM INSTALLATION
Is the installer licensed? —'Y 1-7 SNO
Type of Construction:
NEW REPAIR
New Construction: Certified Plot Plan Review YES a --
Floor Plan Review YES NO
Conditions of Approval from Form U YES NO
Issuance of DWC permit: YE NO
DWC Permit Paid? NO
DWC Permit # ;2,P-7 Installer:
Begin Inspection: YES NO
Excavation Inspection:
Needed:
Passed: .E By:
Construction Inspection:
Needed:
ilt Plan Satisfactory:
S
Approval of Backfill: Date:/,;2 / By:
Final Grading Approval: Date: M? 97 By:
Final Construction Approval: Date: 1Z 16 By;
Certificate of Compliance: Approval. /2/q/ Date: � �
Commonwealth of Massachusetts
W Title 5 Official Inspection Form ✓
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 44 Bridges Lane
Property Address [
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
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 A. General Information
filling out forms
on the computer, **
use only the tab
key to move your 1. Inspector: CItaV ®
cursor-do not John Soucyuse the return Name of Inspector TEU -7
?U12 key.
o 's Sewer Service, Inc.
Company
Compp any Name I UwN OF NORTH ANDOVER
78 N. Broadway HEALTH DEPARTMENT
Company Address
Salem NH 03079
City/Town State Zip Code
603-898-9339 13397
Telephone Number License Number
B. Certification
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
❑
'ed Further Evaluation he Local Approving Authority
®
01/13/2012
sp tors Igna ure Date
e system inspector shall submi/acopy of this inspection report to the Approving Authority (Board
f 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Bridges Lane
'M
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If."not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. CityTrown 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):
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 44 Bridges.Lane
?roperty Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town 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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
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.
9 P
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
s
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'GSM
44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
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): 440
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
<° 44 Bridges Lane
M
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
See Attached
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
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? ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 44 Bridges Lane
M
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Soucy's Septic Service/Summit System
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: Scheduled Pump Service last performed on
04/27/2010
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
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:
1997 Leaching System (Septic tank original)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
20"
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
9
Depth below rade:
p g 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: 6'x11' (1500gal.)
Sludge depth:
2"
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
W title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
i
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
40"
Scum thickness 1/2
Distance from top of scum to top of outlet tee or baffle 7"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? tape &sludge tool
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump the tank once a year.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M
44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
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.):
Box water tight All pipes sealed, even distribution throughout all pipes.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: (3)2'x62'
❑ leaching fields number, dimensions:
❑ 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.):
No signs of any hydraulic back up.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M
44 Bridges Lane
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
.� Tele 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owners Name
information is
required for every m.._.__..__.__.__ _..........
page. City/Town Stag Zip Cade Bate 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
a
zap, g-AA
EB
f
i
, -
i
-� J
7
i
15ms•09M T!ve 5 0:fidai itrspa tion Fora:Svtnurface Sewage Disposai Sys€ern-Page 15 of,?
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Bridges Lane
'M
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town 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: 6'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: 09/29/1997 by Norse Enviromental &
Sandy Star
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Dug hole with Auger in mid drop of area.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Bridges Lane
M
Property Address
Mark Tavano
Owner Owner's Name
information is
required for every North Andover MA 01845 01/13/2012
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Form No.4
Town of North Andover,Massachusetts
BOARD OF HEALTH
__December lg 97
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (X)
by John Soucy
INSTALLER
at 44 Br;does Lane; NorthTpr NLA 01 X45
sly OAffi N
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. 986dated Nov. 13, 1997
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH
euro a a.e4 to nw=y ha=naaron Paye e
• . Town of forth Andover
Tax Map # 210-104.D-0073-0000.0
Parcel Id 16761
44 BRIDGES LANE
TAVANO, MARK
44 BRIDGES LANE
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.08 Acres
FY 2012
UB Mailing Index
NamelAddress Type Loan Number Active/lnact- From Until
TAVANO,MARK Payor
44 BRIDGES LANE
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id.17797.0-44 BRIDGES LANE Last Billing Date 10/4/2011
3170462 03 Cycle 03 Active
UB Services Maint.
Account No.3170462
Service Code Rate Charge MultiplierlUsers
MISCFEE ADMIN FEE 0.63518 7.82 11
WTR WATER 01 ALL METER SIZE 79.80 11
UB Meter Maintenance
Account No.3170462
Serial No Status Location Brand Type Size YTD Cons
35487150 a Active ERT HH b Badger w Water 0.63 0.63 158
Date Reading Code Consumption Posted Date Variance .
12/12/2011 175 a Actual 15 -22%
9113/2011 160 a Actual 21 1011312011 10%
6/7/2011 139 a Actual 18 7/20/2011 -13%
3/7/2011 121 a Actual 20 4/13/2011 12%
12/8/2010 101 a Actual 18 1/12/2011 -36%
9/9/2010 83 a Actual 29 10/15/2010 48%
6/8/2010 54 a Actual 19 7/15/2010 17%
3/10/2010 35 a Actual 16 4/14/2010 -1%
12/11/2009 19 a Actual 17 1/12/2010 63%
9/8/2009 2 a Actual 2 10/15/2009 -100%
8/21/2009 0 n New Meter 0 10/15/2009 -100%
8/21/2009 2784 r Replacement 11 10/15/2009 -36%
6/9/2009 2773 m Manual estimate 20 7/20/2009 36%
MSG
3/16/2009 2753 a Actual 17 4/29/2009 -5%
1218/2008 2736 a Actual 16 1/20/2009 4%
9/11/2008 2720 aActual 17 10/10/2008 -23%
6/6/2008 2703 m Manual estimate 20 7/16/2008 6%
MSG
3/10/2008 2683 a Actual 19 4//112008 4%
12/12/2007 2664 a Actual 20 1/22/2008 -33%
9/6/2007 2644 a Actual 24 10/12/2007 19%
6/20/2007 2620 m Manual estimate 25 7/20/2007 20%
MSG
3115/2007 2595 m Manual estimate 20 4116/2007 -23%
12/12/2006 2575 a Actual =5 1/19/2007 4%
9/13/2006 2550 a Actual 23 10/20/2006 36%
6/19/2006 2527 a Actual 20 7/10/2006 -25%
319/2006 2507 m Manual estimate 20 4/17/2006 26%
MSG
Form No.4
Town of North Andover, Massachusetts
BOARD OF HEALTH
December 919 97
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (x)
by John Soucy
INSTALLE
at 44 Rri dges Tana Nprf-h IlnAn.rer 1�A pl 84
SITE LOCATION r
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. 986 dated Nov. 13 , 1997
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH
i
Town of North Andover, Massachusetts Form No.3
f paerh BOARD OF HEALTH
OL ♦ -19-
DISPOSAL
nDISPOSAL WORKS CONSTRUCTION PERMIT
9SS4CHUSEt
Applicant c �� *�.
.. ... . ....
NAME A D D R ESS TELEPHONE
Site Location
Permission is hereby granted to Construct ( ) or Repair lv an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
.�`J
CHAIRMAN,BOARD OF HEALTH
Fee S D.W.C. No.
SS(.
-
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: ZZ 11416? CURRENT INSTALLER'S LICENSE#
LOCATION: 44 5,&d64 5
LICENSED INSTALLER:
SIGNATURE: TELEPHONE#
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. -
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As-Built? Yes No
Floor Plans? , Yes
Approval ///�: / la�� Date:
TO: NORTH ANDOVER, MASS 19 P4L
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
L® f--3 jP�GE.S 1-19LNH North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
4 - ;2 3 0 C0414f �
z o
cm
gimme g. nitarian
9��qN S113S�a�
Town of North Andover, Massachusetts Form No. 1
F NORTH q• BOARD OF HEALTH ///E `/�� { /
3?°�AS`ED io`/
`96'YOL ,�J Ua� 19Lf�
`Ac° gym ' APPLICATION FOR SITE TESTING/INSPECTION
7�AOAA TED
SSAC14US�
Applicant �/�T/2/C�
NAMMEA ADDR// S TELEPHONE
Site Location ��/��� G'4
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test No. (51¢
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
01 E D �41
0 19
O
APPLICATION FOR SITE.TESTING/INSPECTION
SACHUS���h
Applicant '
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee - Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Norse Environmental 2 6 I P.02
=moi
144-
A 44A
S-So,5' i
• r — � �x. TANK -
� O
VEp4 r t
- l
$• 35.5
A-p44,d i
A
$-43
AS-BUILT SURVEY
44 BRIDGES LANE
NO.ANDOVER,MA
SCALE 1"=20'
DATE: 12-1-97
Owner: Mulcahy
Installer:J. Soucy
Location Elevation
r Top Foundation. ...........99.90
Tank Outlet...................95.49
D-Box Inlet....................94.50
D-Box Outlet.................94.33
Beg. Trench#1.............94.33
#2..................94.01
#3..................93.80
End Trench#1.............93.98
^ #2.....................93.74
"
#3—.... .............93.52
Bat.Trench#i..............91.98
.� #2...................:.91.74
#3.....................91.52
Norse Environmental 2 6 1 P. 01
NORSE ENVIRONMENTAL SERVICES, INC.
.1 3 Pandview Place
Tyngsbaro,Mass.01879
TEL.649.9932 • Fax 649-7582
CERTIFICATION OF SUBSURFACE SEWAGE a
DISPOSAL SYSTEM INSTALLATION
1, Steven Eriksen, a Registered Sanitarian duly licensed by,the Commonwealth of
Massachusetts, License.#886, and working as an employee for Norse Environmental
Services Inc. certify that we have performed a final inspection of the subsurface
sewage disposal system at the referenced location in accordance with 310CMR15.021.
To the best of my knowledge and belief all work shown on the accompanying As-Built
Plan has been completed in general compliance with the original design plans as
approved by the local Board of Health. Furthermore, the work as shown on the As-Built
Plan appears to comply with the provisions of Title 5 of the Massachusetts
Environmental Code (310CMR15.000) and all applicable local requirements.
LOT NUMBER: #44 BRIDGES LANE
STREET ADDRESS' BRIDGES LANE
TOWN:NO. ANDOVER +
DATE: 12-1-97 `tN OF
STEVENy��,
SIGNATURE: L: ERttcS£N N;k,
'E''�A No.885
SQNrTA'9LX
R'
r NORSE ENVIRONMENTAL SERVICES, INC.
3 Pondview Place
Tyngsboro, Mass. 01879
TEL. 649-9932 FAX 649-758 TQ' j LL
j
10-21-97
No. Andover Board of Health
r "
Town Offices
No. Andover, MA 01845 � 997
x
Re: 44 Bridges Lane ..�.-.
Dear Board Members;
On behalf of our client, Mr. Pat Mulcahey, we are hereby requesting the following
variances to the local regulations for the repair to an existing septic system.
Regulation 14.18 Distances
Leaching Facility to Wetlands (100' req'd - 78' prop.)
Leaching Facility to Cellar Wall (35' req'd - 20' prop.)
The reasons for the requests are due to the existing location of the house and
wetlands.
If you have any questions or comments, please do not hesitate to contact us.
Respectfully,
� •' y- •? r d� wu}3
`� Steven Eriksen
'S No......_._........................._. Date c 22 c-9
-�-�
�:� • ' Commonwealth of Massachusetts - -
Massachusetts
Soil Suitability Assessment for On-site SewageZh'sosal
o fd2'�7 (�2,�fCr
Wimessed By:
L=,,—,.de-_Sl x
21 P&eG Li}N!s Add�.w PA}TC i GK 14�LL/�/7/G'(
• A/0 P-Vi AL/✓Do✓eg -
New Construction Q Repair (�
Office Revie'PI
Published Soil Survey Available: No Q Yes
' Year Published _.. � ®oo_
..... Publication Scale ...1._°.ZS Soil Map Unit .G.r.L
Drainage Class U!.a.... Soil Limitations .....................
Surficial Geologic Report Available: No Yes ❑
Year Published _......:......... Publication Scale ................
Geologic Material U'vlap Unit) ........... ..............................................................-.._.•. .
Landform ...................................................................
Flood Insurance Rate Map:
Above 500 year Hood boundary No Q Yes Q
Within 500 Ye-='i flood boundar e
y No Yes
s _
Within 100 year flecd boundary Na Yes .
Q
National Wetland Inventory Map (reap unit) .
Wetlands Conser-vancy Program: %lea (rmao unit) .
Current VNater Resource Ccndit:cns (USES): Month =
Rang= : Above Normal QNormal Q Hetc�v Normal
Q-�nr
Re-arances Nei
g7 - - - -- - --- -
bUI^ 8iVALKJATOR FOFIY1
Page 2
. .
On-site Review
.
.
�
`
Deep Hole Number /d.-.-�' Date: ��me� /�'`���� � Weather --------------`
Location (identify onsite plan) '— ______`_________________________________
Land Use ....... .e^�e.................................. Slope (96> -0'7:�- Surface Stones -- .
Vegetation ................. _-----_—_.
Landform ---1/,yx ��. -. /* .....
—'�---...........
...............
_.......
......
............
___________
Posidononlandscape (sketch onthe badW ------_______ '_________
Distances from: -
Open Water Body ..... feet Drainage way Z(!�° feet '
Possible Wet Area feet Property yLine -'
feet
Drinking Water Well .7'�....... feet Other -............. ... - '-DEEP.OBSERVATION J-10-11T LOG
—
�
Depth fro M Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(inches) (USDA) (Munseil) (Structure, Stoces, Boulders,
7-1
YO r5
�
. .
�
� .
/
�
�
�
/
�
�
�
� ParentMaterial (geo|ogic) '2447��� -_................................................... '- Depth to Bedrock:
.
Deoth to
Standing Wa-,a, in the Hole: Weeping hnm F5r Face:
--_'-
' .
Estimated Seasonal High Ground Water: -;>/19m~~
� . .
�
. . '
yt. y . L A.A. �"... LTr%LAuC11vimPWe3
.IVB
Determination ,for Seasonal High Water Table
t Method Used:
�I
❑ Depth observed standing in observation hole..___._ inches
❑ Depth weeping from side of observation hole..______ inches
0'Depth to soil mottles ..7!.°. inches
❑ Ground water adjustment .................. feet
Index Well Number ................... Reading Date .................. Index well level ....__........__.
/e
t1 �% factor tQ� J lrtlElll GV Vr ............ I(ICfod cround Yvarerlevel _
Deoth of Naturally Occurrina Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
t
If not, what is the depth of naturally occurring pervious materia(?
Certification
I certi y that on 9 (date) I have passed the examination approved by the
Department of Env ronmental Protection and that t e bove analysis was
performed by me consistent with the required trai in , expertise and experience
described in 310 CMR 15.017.
3 gnature Dat= ° z 4
pOR71y
BOARD OF HEALTH
3? . . • OL
• i a
146 MAIN STREET TEL. 688-9 540
0..,5
'SSACH USE` NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE. .c�
LOCATION OF SOIL TESTS: -f4 "BAM4,�Z5
Assessor's map & parcel number:
OWNER: k (. , TEL. NO.:
ADDRESS: `'E Lt 9/ r�vc C�
ENGINEER:N g(- &-h"V Laj dY4.wQ L TEL. NO.: -50S'
CERTIFIED SOIL EVALUATOR:
Intended use of land: residential subdivision, single family home, commercial
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1
. -Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of $175.00 per lot for new construction. This covers the two deep holes
and two percolation tests required for each lot. Fee of $75.00 per lot for
repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design
septic plans.
3. At least two deep holes and two percolation tests are required for each septic
system.
4. Repairs require at least two deep holes and at least one percolation test, at
the discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of
testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be
submitted to the Board of Health showing the location of all tests (including
aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
tit Norse Env i t onmont a I 2 6 1
__..............
_....__.
Commonwealth of Massachusetts• bate LES a-y_
• , Massachusetts
Soil Suitability Assessment or •On-cite CawQm
s o alto
} Performed By:
Wtctessed By:
. • y� b rcr v�G3 Ls}Nam �,.w �9T1t i cK N1 JI�G/�/���
/U o rz sl;i A�NQa✓G1'� ray,,,,., .
New ConsZ-uction ❑ Repair
Office Rirvi"rt
Published Soil Survey Available: No ❑ Yes F
' Year Pub
--- Publication Scale
car G
Drainage Class I✓.D..,• Soil Map Unit...................
Soil Linlita.;ions ............._._.............
Surficial Geologic Repot Available: No Yes ClG .
Year Publishad ........:._...... Publication Scale
Geologic Material (Map Unit) ............ .................. .
_......................._.....................__...
Flood Insurance Rate Map ..._...................................: -. ...
Above 500 year flood boundary No ❑ Yes Q
Within 500 year flood boundary Na d Yes ❑
Within 100 year flood boundary Q
. f No Q Yes
Wer!and Area:
National Wetland Inventory f41ao (map unit)
f
Wetlands Conservancy Pro ra ,
g n Map (reap unit). .
........... �
Currant Wa:er Rasour-e Conditions (USGS): .
•t4tonth
Rance : A;:ove Normal ❑ Nornmal ❑
t Belo
w Ncrzal
Other References Revie,r4ad•
Post-Ito Fax Note 7671 Date y
To Pages
Phoned �. �- _ '�.-__—_`•ti„--•...,.�.– •,
Phone rt
Fax V
Fax N
e5 44-4 a tURM-TY-�-SCIEL--EVAILVX-TOIR FORM
Page 2
Onsite
Review
Deep Hole Number Date: 11:!Y?:I Time: Weather ..................
...........
Location (identify on site plan) .........s..<.-,S
Land Use .......
..............
.................. Slope Surface Stones ...
Vegetation ........... ...........................
Posit on on landscape (sketch on the back) ....................................
Distances from: .............. ...... .......................................
Open Water Body X#a- feet Drainage way e_,e 'feet
Possible Wet Area 2.p?# feet Property Line .'feet
Drinking Water Well feet Other
DEEP
Depth From Surface Soil Horizon Soil Texture Sail Color
"Tex
(inches) (USDA) (Munsell) Sol,Mowing Other
(Structure,StOOes,Boulders,
Soil Colo'
(Munsell)
Consistency. 94 Gravel}
All
7
C-
efd?
tn—er
Parent Material (geologic)
.......................................... Depth to Bedrock:
2-20th :0 Groundwater: Standing Wa-,e.- in the Hole: ............... Weeping from pit Face:
Estimated Seasonal High Ground Water:
Z I--0-4UaWU0-4 ) ^U3 OS.AON
i
� . :.. •. - ��u.�r.vai.aA:v�-rvcuvL-
N 015 Page 3
.
Determination for Seasonal H[eh Water Table
' Method Used:
❑ Depth observed standing in observation hole-.____— inches
❑ Depth weeping from side of observation hole.._—__ inches -
Depth to soil mottles .. i..�. inches
❑ Ground water adjustment ........... feet
lrrde:x Well Number................... Reading Date ...... ...._._. Index well level ...._............
Adjustment factor .......... Adjusted ground water level ................:.........._............._...........
Decth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material?
Certification
1 certify that on (date) 1-have passed the examination approved by the
Departrnent of Env roal Pr
ote_�ion and that t e bone analysis was
performed by rare consistent with the required trai in , expertise and experience
described in 310 CMR 15.017.
Signature { Date
£0'd T 9 Z 1i0luawuoa1nu3 '9S-40N '
Norse Environmental 2 6 1 P.91
NORSE ENVIRONMENTAL SERVICES, INC.
3 Pondview Place
Tyngsboro,Mass.01879
TEL 649-9932 • FAx 649-7582
FAX TRANSMITTAL COVER SHEET
DATE:
TO: J��Nfa y c5'7��'12
FROM:
RE: +6 60elo44-s Lac.)
NO. OF PAGES (incl. cover) g
r !n) (
1
Mill
Ci
a t YA
M ± }
Tf.t..i 4 t XIl Ott }, '�i• /�� ♦ I �
� r
r is,�titf{;rarits�y �'4��dcr�k""
I` r }'111y ♦ �C
a'
."1 i a i. SS 1S.�.t;_7 � f Ott •�:;.
ui �..
Eli
t e 3! }
y,er�., ars
�
It`r
i�s ii�,� to
4111
c t 1 Y
DATE: ?7
LOCATION:
ENGINEER:
BOH WITNESS:
PERCOLATION TEST#
BOTTOM DEPTH OF PERC TEST: G "
TIME OF SOAK: (At least 15 minutes long)
TIME AT 12"
TIME AT 9"
TIME AT 6" 1
OVERNIGHT SOAK
TIME STARTED
NEXT DAY SOAK: (At least 15 minutes)
TIME AT 12"
TIME AT 9"
TIME AT 6"
SEPTIC PLAN SUBMITTALS
LOCATION:
NEW PLANS: $60.00/Plan
REVISED PLANS: YES $25.00/Plan
DATE: 3 7
s
DESIGN ENGINEER:—
When the submission is all in place, route to the Health Secretary
1 _
Town of North Andover, Massachusetts Form No.2
f NORTH BOARD OF HEALTH
T3 192-7_
� w
9
DESIGN APPROVAL FOR
1SSACHUSOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant__ PT /v�(1G� r���� Test No.
Site Location
Reference Plans and Specs. Ai'045E
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
• r
"CHAIR AN,B ARD OF HEALTH
LFe �7s Site System Permit No. ��
1 NORSE ENVIRONMENTAL SERVICES, INC.
3 Pondview Place
Tyngsboro, Mass. 01879
TEL. 649-9932 - FAx 649-7582
CERTIFICATION OF SUBSURFACE SEWAGE
DISPOSAL SYSTEM INSTALLATION
I, Steven Eriksen, a Registered Sanitarian duly licensed by.the Commonwealth of
Massachusetts, License #886, and working as an employee for Norse Environmental
Services Inc. certify that we have performed a final inspection of the subsurface
-sewage disposal system at the referenced location in accordance with 310CMR15.021.
To the best of my knowledge and belief all work shown on the accompanying As-Built
Plan has been completed in general compliance with the original design plans as
approved by the local Board of Health. Furthermore, the work as shown on the As-Built
Plan appears to comply with the provisions of Title 5 of the Massachusetts
Environmental Code (310CMR15.000) and all applicable local requirements.
LOT NUMBER: #44 BRIDGES LANE
STREET ADDRESS: BRIDGES LANE
TOWN:NO. ANDOVER +
DATE: 12-1-97 . ��`�� OF M(rs9c
Or 9G
STEVEN
SIGNATURE: L ERIKSEN
•
�EctST ERS°
SAN�rAR�P`'
t �!
r a.
A-Qc
..
Fit 44
B
L O VEu r
R- 44
A -SZ,S�
AS-BUILT SURVEY
44 BRIDGES LANE
NO. ANDOVER, MA
SCALE 1"=20'
DATE: 12-1-97
Owner: Mulcahy
Installer: J. Soucy
Location Elevation
Top Foundation.............99.90
Tank Outlet...................95.49
D-Box Inlet....................94.50
D-Box Outlet.................94.33
<:
Beg. Trench#1.............94.3
#2..................94.01
#3..................93.80
End Trench#1.............93.98
#2.....................93.74
#3.....................93.52
Bot. Trench#1..............91.98
.•<< , �� #2.....................91.74
DATE: — 7
LOCATION: 4 r �-
ENGINEER:
BOH WITNESS: P-Z'Ij
PERCOLATION TEST# l
BOTTOM DEPTH OF PERC TEST:
TIME OF SOAK: (At least 15 minutes long)
TIME AT 12"
tel'
TIME AT 9"
TIME AT 6" V
OVERNIGHT SOAK
TIME STARTED
NEXT DAY SOAK: (At least 15 minutes)
TIME AT 12"
TIME AT 9"
TIME AT 6" 3
Norse Environmental 2 6 1 P. 01
.1
NORSE ENVIRONMENTAL SERVICES, INC.
r. 3 Pondview Place
' Tyngsboro,Mass.01879
TEL-649-9932 - FAX 649.7582
CERTIFICATION OF SUBSURFACE SEWAGE :
DISPOSAL SYSTEM INSTALLATION
I, Steven Eriksen, a Registered Sanitarian duly licensed by.the Commonwealth of
Massachusetts, License #886, and working as an employee for Norse Environmeltal
Services Inc. certify that we have performed a final inspection of the subsurface
sewage disposal system at the referenced location in accordance with 310CMR15.021.
To the best of my knowledge and belief all work shown on the accompanying As-13uilt
Plan has been completed in general compliance with the original design plans as
approved by the local Board of Health. Furthermore, the work as shown on the A:-Built
Plan appears to comply with the provisions of Title 5 of the Massachusetts
Environmental Code (310CMR15.000) and all applicable local requirements.
LOT NUMBER:" #44 BRIDGES LANE
STREET ADDRESS: BRIDGES LANE
TOWN.-NO. ANDOVER +
DATE: 12-1-97 `1H OFC�G
4
I STEVEN
SIGNATURE: �L:
7 ERIICSEN Hn
14M sss
�rfe
SQNIT
i
• f Pa9eS� ?
7671
Pos1
-1V fax Note
Co. ;
ep1 j � J Phone
Phone Fax M
Fax# _ _
Worse Environmental 2 6 1 P. 02
'
44-
A
-4A - :33 'D-Ez7k K
r — --� Ex. TANK
VEm r r
— _ #L
A-
f
*3 $•3'5.5
i
ft--44,o'
4 its
$-ss.z
A- S7.5 A-52,51
-BUILT SURVEY
i BRIDGES LANE
140.ANDOVER, NIA
SCALE 1"=20'
DATE: 12-1-97
Owner: Mulcahy
Installer: J, Soucy
Location Elevation
Top Foundation.......--.99.90
Tank Outlet.......... ........95.49
D-Box Inlet....................94.50
D-Box Outlet........ ........94.33
Beg.Trench#1.... ........94.33
a Q #2..................94.01
.. �. #3......... ........93.80 '
End Trench#1.............93.98
„ #2............ 93,74
#3. .......... ........93.52
Bot. Trench#1..............91.98
,. #2.....................91.74
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617-29?-5500
t -
WILLIAM F.WELD TRUDY CORE
Govemor
`� 15 Secretary
t9�� 3 �
ARGPAUL CELLUCCI AVID B.STRUHS
Lt.Gov
ernor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR ,- Corhm issioner
PART A
CERTIFICATION
Property Address: 44 Bridges Lane, N.Andover, MAAddress of Owner:
Date of Inspection: 7/2 3/9 7 (If different)
Name of Inspector: James W. Wright, Jr.
la'm a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Nme: R.J. Inspections
Mailing Address: 1 nsgood Street, Met-hw—n, MA
Telephone Number: _ 508 681 -8759
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:
_ Passes
— Conditionally Passes
�� s Further Evaluation By the Local Approving Authority
f/ F ils
Inspector's Signature: ?r/ /� Date:
The System Inspe o shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If t ystem is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 31.0 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) page 1 of 10
DEP on the World Wide Web: http:/Avww.magnetstate.ma.usidep
>E'j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 Bridges Lane, N.Andover, MA
Owner: Donna Harris
Date of Inspection: 7/2 3/9 7
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if.(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to 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 1 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 04/25/97) Page 2 of 10
- " - --SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:44 Bridges Lane, N.Andover, MA
Owner: Donna Harris
Date of Inspection: 7/2 3/9 7
Dj SYSTEM FAILS:
Youm indicate ei,!-.er "Yes" or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
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($).
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" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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/withi !2
a surface drinking water supply
the system '' f riyt o a t butary to a surface drinking water supply
the system itrogen sensitive area(interim Wellhead Protection Area•IWPA) or a mapped Zone II of a
public water
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
PART B
CHECKLIST
Property Address: 44 Bridges Lane, N.Andover, MA
Owner: Donna Harris
Date of Inspection?/2 3/9 7
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 N/A.
/ 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.
v _ 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:
✓✓✓ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. 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)]
(revised 04/25/97) page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 44 Bridges Lane, N. Andover, MA
Owner: Donna Harris
Date of Inspection: 7/23/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.dJbedroorn for S.A.S.
Number of bedrooms.2
Number of current residents:
Garbage grinder (yes or no):"
Laundry connected to system (yes or no):Z
Seasonal use (yes or no):"
Water meter readings, if available (last two (2) year usage (gpd-f
Sump Pump (yes or no): -
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: /iilagle:
'
Grease trap present
Industrial Waste Hresent: (yes or no)_
Non-sanitary wa to the Title 5 system: (yes or no)_
Water meter rea in
Last date of occu ancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)
If yes, volume pumped: alIons
Reason for pumping:
TYPE OSYSTEM
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. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 43
Sewage odors detected when arriving at the site: (yes or no)��
(revised 04/25/97) Page 5 of 10
-SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Bridges Lane, N. Andover, MA
Owner: Donna Harris
Date of Inspection: 7/2 3/9 7
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iro _40 PVC_other (explain)
Distance from privatew p y II or suction line
Diameter
Comments: (condition of joi s, a ting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
II
Depth below grade:
Material of construction: oncrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: !n x- /rl
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle:,&L
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:LO
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integn evidence of leak a etc.
40
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 top outlet tee or baffle:
Distance from bottom o c m of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pu ping; condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) page 6 of 10 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Bridges Lane, N. Andover, MA
Owner: Donna Harris
Date of Inspection: 7/2 3/9 7
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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: gallon ay
Alarm level: in rk* der_Yes; _ No
Date of previous pumpi g:
Comments:
(condition of inlet tee, conditi of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: 3
Comments:
(note if level and distribution is equal, a idence„of solids carryover, evidence of leakage into or out of box,etc.)
-cn/
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Ye-j or No
Comments:
(note condition of pum(chs r o clition of pumps and appurtenances, etc.)
(zavis�d 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
--PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Bridges Lane, N. Andover, MA
Owner: Donna Harris
Date of Inspection: 7/2 3/9 7
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimension
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failum—level of onding condition of vegetation, etc.)
5 _ On
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet inve :
Depth of solids layer:
Depth of scum lay
Dimensions of c spool:
Materials of constructio .
Indication of groundw ter.
inflow (ce pool 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: l "
(note condition of soil, signs f ulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) page 8 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Bridges Lane, N. Andover, MA
Owner: Donna Harris
Date of Inspection: 7/2 3/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
x
� Boa
I
(ravisad 04/25/97)� X97) PaSia 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address-44 Bridges Lane, N. Andover, MA
Owner: Donna Harrsi
Date of Inspection: 7/2 3/9 7
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
t Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how
you established the High Groundwater Elevation. Must be completed)
LOP
(revised 04/25/97) ?age 10 0! 10
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