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HomeMy WebLinkAboutMiscellaneous - 46 RALEIGH TAVERN LANE 4/30/2018 (3) 46 RALEIGH TAVERN LANE 210/107.A-0106-0000.0 a, mai ;, i . dli UPC 14081 No. PC402-2A-2 -QCT i9AOflNOO.(� i North Andover Health Department Community and Economic Development Division 10/5/16 Address: 46 Raleigh Tavern Lane All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed,the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept@northandoverma.gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely, A w rian LaGrasse, CEHT Director of Public Health 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.northandoverma.gov � � �r ��� Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form SEP 2 9 2016 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments TOWN OF NORTH ANDOVER 46 Robert Bennett HEAL% DEPARTMENT CNI Property Address V-tqq, 6r 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification 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 ❑ NepAs Further Eypluation by the Local Approving Authority s 9/19/2016 lnsp*toh Si ature V 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. r ****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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 / 1 Commonwealth of Massachusetts U, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owners Name information is required for North Andover MA 01845 9/19/2016 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•3113 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 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavem Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavem Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3113 Me 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Citylrown 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: Pumped 2015,owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measure tank. Reason for pumping: Inspect tank&tees. 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•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 y` 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 10 years old, 8/17/2006, info at B.O.H.. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.4 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, 4"&3" PVC in house, no leaks visible. Septic Tank(locate on site plan): Depth below grade: 0.4 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 L Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 11" 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 ok. Outlet filter clogged, clean same. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover 1"deep. Outlet cover 2"deep. Pumped septic tank. 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•3/13 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 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 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 Forth: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 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown 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 level&distribution equal has flow levelers. No evidence of leakage. Evidence of light carryover, pumped d-box to clean. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 54 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Six chambers per nine lines. 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•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 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately See I a OR a =, � 04BOr a ; 4 2 kk l( t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 46 Robert Bennett Property Address 46 Raleigh Tavem Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 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: 2/16/2005 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Robert Bennett Property Address 46 Raleigh Tavern Lane Owner Owner's Name information is required for North Andover MA 01845 9/19/2016 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • ounnary meww Baru gunuidmu un w wicu to t.to.vu nn uy raid nuney adv Town of North Andover Tax Map # 210-107.A-0106-0000.0 Parcel Id 17932 46 RALEIGH TAVERN LANE BENNETT, ROBERT Since Jan 2011 BENNETT, EUGENIA 46 RALEIGH TAVERN LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zon1ng3 1 Residential Size Total 1.02 Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until ROBERT BENNETTE Owner 46 RALEIGH TAVERN LANE NORTH ANDOVER,MA 01845 LINDLEY,JAMES Previous Customer Inactive 7/29/2004 46 RALEIGH TAVERN LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14207.0-46 RALEIGH TAVERN LANE Last Billing Date 9/12/2016 2100203 02 Cycle 02 Active UB Services Maint. Account No.2100203 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 1,119.40 /1 UB Meter Maintenance Account No.2100203 Serial No Status Location Brand Type Size YTD Cons 17526666 aActive ERT HH b Badger w Water 1 1 3139 Date Reading Code Consumption Posted Date Variance 8/3/2016 4993 aActual 208 9/21/2016 1812% 5/4/2016 4785 a Actual 11 6/21/2016 -21% 2/2/2016 4774 a Actual 14 3/28/2016 -92% 11/2/2015 4760 a Actual 177 12/30/2015 5% 8/4/2015 4583 a Actual 173 9/14/2015 504% 5/4/2015 4410 a Actual 28 6/22/2015 10% 2/3/2015 4382 a Actual 26 3/20/2015 -84% 11/3/2014 4356 aActual 169 12/15/2014 29% 8/1/2014 4187 aActual 123 9/11/2014 142% 5/5/2014 4064 a Actual 52 6/12/2014 247% 2/4/2014 4012 a Actual 16 3/17/2014 -93% 10/31/2013 3996 aActual 227 12/20/2013 488% 8/1/2013 3769 aActual 39 9/18/2013 10% 5/1/2013 3730 aActual 32 6/18/2013 127% 2/7/2013 3698 a Actual 17 3/13/2013 -90% 10/30/2012 3681 a Actual 158 12/13/2012 -34% 8/2/2012 3523 a Actual 247 9/26/2012 356% 5/2/2012 3276 a Actual 53 6/20/2012 321% 2/2/2012 3223 a Actual 13 3/14/2012 -91% 11/1/2011 3210 aActual 143 12/15/2011 -12% 8/2/2011 3067 a Actual 165 9/14/2011 1100% 5/2/2011 2902 a Actual 13 6/13/2011 -5% 2/4/2011 2889 a Actual 15 3/15/2011 -92% 11/1/2010 2874 aActual 187 12/13/2010 33% Commonwealth of Massachusetts City/Town of . System Pumping.Record Form 4 DEP has provided this form for us&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., ' heck 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 Locab ; L f ght rout of Hous ft/Right rear of house, Left/right side of house, Left/ Right side of b , Left/Rig ron of building, Left/Right rear of building, Under deck . Address 3 Citylrown State Zip Code 2. System Owner. Name Address(if different from location) Citylrown . State -3�--- �Zp�� y ; Telephone Number ; .B. Pumping Record 1. Date of PumpingDate 2- Qua tity Pumped: Gallons4 .3. Type-of system: E] Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? 0-- e,,s ❑ No if yes,was it cleaned? r es ❑ No, ' 5. Condition of Syst 6: System Pumped By: Neil.Bateson ' F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati a contents were disposed: -LS Lowell Waste Wafer Sign a 9t Hauleru Date t5form4.doc 06/03 . System Pumping Record•Page 1 of 1 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 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. RECLIVUB Important: A. General Information When filling out APR 1 4 2014 forms on the " computer,use 1. Inspector: only the tab key TOWN OF NORTH ANDOVER to move your Neil J. Bateson HEALTH DEPARTMENT cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name Q 111 Argilla Road Company Address Andover MA 01810 City/Town 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 ❑ Nee FurthEft Evaluation by the Local Approving Authority A&- 4/8/2014 Inspfc16rs%tignatureV 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 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavem Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t " 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. City/Town 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 �Un Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every 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 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 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 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3/13 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 46 Raleigh Tavern Lane Property Address Robert Bennett Owner owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 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•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane Property Address Robert Bennett Owner owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Never pumped Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2000 gallons How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank&tees 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 or 17 Commonwealth of Massachusetts Uvov Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is North Andover MA required for 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 8 years old, 8/17/2006, Info at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.4 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, 4"&3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: .4 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: 8" 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 46 Raleigh Tavem Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 6" 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 clogged, clean same. Outlet tee ok. Outlet filter clogged , clean same. Depth of liquid above outlet invert, filter clogged. 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 Forth: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 46 Raleigh Tavem Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 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•3113 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 t 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown 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 level &distribution equal, has flow levelers. Evidence of carryover, pumped d-box to clean. No evidence of leakage. 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 Commonwealth of Massachusetts tuTitle 5 Official Inspection Form gq- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane j Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 � every page. Cityrrown State Zip Code Date of Inspection D. System Information (coni, .) Type: ❑ leaching pits number: ® leaching chambers number: 54 i ❑ leaching galleries number: I ❑ leaching trenches number, length: ❑ leaching fields i 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.): Soil ok. Vegetation ok. No sign of Bonding to surface. Six chambers per nine lines i Cesspools (cesspool must be pum�ed 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•3/13 Title 5 Official Inspection Forth: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 .�41 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown 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 Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r� R, � a — t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owners Name information is required for North Andover MA 01845 4/8/2014 every 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: 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: 2/16/2005 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Raleigh Tavern Lane Property Address Robert Bennett Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Citylrown 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-3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts City/Town of . System Pumping Record Form 4 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 1. System Locatio ee Rig nt ofho eft/Right rear of house, Left/right side of`house, Left/ Right side of bulldtlfg, Left/Right front of building, Left/Right rear of building, Under deck Address 4G G cityrrown state by Code 2. System Owner. Name Address(if different from location) cityRown i Zip code Telephone Number "> B. Pumping Record 1. Date of Pumpingoar 2. Quantity Pumped: Gallons 3. Type of system. ❑ cesspool(S) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? 34e-,-s U No If es, was it cleaned? e . Y s ❑ Ne, ' 5. Condition of System✓�' �� � C 1.`Y/� ��-�- 6.- System Pumped By: Nell.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Location wtkre contents-were disposed: S Lowell Waste Water Sign Hsu Date t5form4.doc•06103 System Pumping Recons•Page 1 of 1 - Summary Record Card generated on 3/312014 2:05:53 PM by Maureen McAuley Page 1 Town of North Andover Tax Map # 210-107.A-0106-0000.0 Parcel Id 17932 46 RALEIGH TAVERN LANE ROBERT BENNETTE 46 RALEIGH TAVERN LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.02 Acres FY 2014 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until ROBERT BENNETTE Owner 46 RALEIGH TAVERN LANE NORTH ANDOVER,MA 01845 LINDLEY,JAMES Previous Customer Inactive 7/29/2004 46 RALEIGH TAVERN LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14207.0-46 RALEIGH TAVERN LANE Last Billing Date 3/6/2014 2100203 02 Cycle 02 Active UB Services Maint. Account No.2100203 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 60.80 /1 UB Meter Maintenance Account No.2100203 Serial No Status Location Brand Type Size YTD Cons 17526666 a Active ERT HH b Badger w Water 1 1 2158 Date Reading Code Consumption Posted Date Variance 2/4/2014 4012 a Actual 16 3/17/2014 -93% 10/31/2013 3996 a Actual 227 12/20/2013 488% 8/1/2013 3769 a Actual 39 9/18/2013 10% 5/1/2013 3730 a Actual 32 6/18/2013 127/, 2/7/2013 3698 a Actual 17 3/13/2013 -90% 10/30/2012 3681 a Actual 158 12/13/2012 -34% 8/2/2012 3523 a Actual 247 9/26/2012 356% 5/2/2012 3276 a Actual 53 6/20/2012 321% 2/2/2012 3223 a Actual 13 3/14/2012 -91% 11/1/2011 3210 a Actual 143 12/15/2011 -12% 8/2/2011 3067 a Actual 165 9/14/2011 1100% 5/2/2011 2902 a Actual 13 6/13/2011 -5% 2/4/2011 2889 a Actual 15 3/15/2011 -92% 11/1/2010 2874 aActual 187 12/13/2010 33% 8/3/2010 2687 a Actual 144 9/13/2010 578% 5/3/2010 2543 a Actual 21 6/9/2010 31% 2/1/2010 2522 a Actual 16 3/11/2010 -78% 11/2/2009 2506 a Actual 74 12/11/2009 -42% 8/3/2009 2432 a Actual 124 9/11/2009 170% 5/7/2009 2308 a Actual 49 6/16/2009 164% 2/2/2009 2259 a Actual 18 3/16/2009 -89% 11/3/2008 2241 a Actual 169 12/10/2008 -25% 8/1/2008 2072 a Actual 218 9/12/2008 627% 5/2/2008 1854 a Actual 29 6/18/2008 84% 2/4/2008 1825 a Actual 17 3/14/2008 -90% 11/1/2007 1808 aActual 164 1/15/2008 12% � �10RTH q _ i' 4°'�- •• OL 1 , A IMM ebb 04 e"mN wKw 1' ��SSgcHus PUBLIC HEALTH DEPARTMENT [ommunity Development Division C'FRTj1FIC. 4T1F OF C0qq,1D'- T3Xff As of.- August f:August 17 2006 'Ifiis is to cert that the indviduaCsu6surface disposafsystem was: Fully Repaired by.. Warren Pearce 46Raleigh Tavern Gane Yorth Andover, 9WA 01845 The Issuance of this certifi'cate shaff not 6e construed as a guarantee that the system wiff function satisfactorify. Sus T Sawyer, WfS ISS Tu6Cic.IfeaCth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com V TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System constructed; ( )repaired; /' I by A.,ma located at 411 -Cr - ^` was installed in conformance with the North Andovej Board of Health approved plan, System Design Permit# ,plan dated J a 2--11°-S , with a design flow of-f SO gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: Engineer Representative Final inspection date: g11L0 Engineer Representative Installer: Lie.#: Date: Engineer: 0Date: �6 rr `� tAE�V � T � �� JGH �-� ** f40. 38706 AUGCIVIL 1 2006 ?; , F " � [RE EALTH DEPAi2TM TER ��"� rJJY+ +•. Environmental Consultant JAMES M.KAVANAUGH,P.E. •Real Estate Brokerage 14 Shady Hill Drive • Septic System Designs North Reading,MA 01864 •Construction Services (978)664-2925 •Custom Home Builder August 16, 2006 Board of Health Town of N. Andover 1600 Osgood Street N. Andover, MA 01810 Ry!'� '� Att: Susan Sawyer Re: Septic System TCS +LTH DEPP'-THR N ENT R 46 Raliegh Tavern Lane Dear 40n:5aj'ezX-.,. Enclosed please find 6 copies of record drawings for the above referenced property. This letter is to notify the Board of Health that I, James M. Kavanaugh, P.E., certify that the system has been installed according to the approved plan. If you have any questions or comments please do not hesitate to contact me at(978)664-2925. Sincere James M. Kavanaugh, P.E. c�rf' w x r� x rye Enc. "K ca I L 766 ' y { :µ. I TOWN OF NORTH ANDOVER Ot gORTFI Office of COMMUNITY DEVELOPMENT AND SERVICES f _ p HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 '..0 S� Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX ADDRESS: 46 Raleigh Tavern Lane MAP: LOT: INSTALLER: Warren Pearce, Pearce Construction DESIGNER: James Kavanaugh PLAN DATE: 10/24/05 Rev. 10/24/05 BOH APPROVAL DATE ON PLAN: 10/31/05 DATE OF BED BOTTOM INSPECTION: 11 1) 61 K DATE OF FINAL CONSTRUCTION INSPECTION: 11/17/05 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS 0 Existing septic tank properly abandoned 0 Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged O 1500 gallon tank installed H-20 loading 2-piece ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) 0 Inlet tee installed, centered under access port [KI Outlet tee (effluent filter) installed, centered under access port IRI 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present 0 Hydraulic cement around inlet & outlet Comments: Poly-lok filter installed Page 1 of 3 TOWN OF NORTH ANDOVERT'20 t Office of COMMUNITY DEVELOPMENT AND SERVICES �?•`i+_ p HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 �'Ss"„CHU t� Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX D-BOX El Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) 0 Hydraulic cement around inlet & outlets 0 Observed even distribution Comments: Levelers provided SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan 0 Size of SAS excavated as per plan 0 Title 5 sand installed, if specified on plan 0 laterals installed and ends connected to header (and vented if impervious material above) 0 Gravelless disposal systems: type, number and location as per plan 0 Elevations of laterals installed as on approved plan El 40 Mil HDPE barrier installed ❑ Final cover as per plan Comments: Page 2 of 3 r� TOWN OF NORTH ANDOVER ` °r °60 , Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER,MASSACHUSETTS 0 184 �'&,gcHU Susan Y. Sawyer, REHS/RS 978.688.9540-Phone Public Health Director 978.688.9542-FAX SYSTEM ELEVATIONS Benchmark: 100.00 Rod at Benchmark: 2.95 Height of Instrument: 102.95 INVERT ON DESIGN PLAN INVERT ELEVATION Building Sewer OUT 99.25 99.35 Septic Tank IN 9885 98.91 Septic Tank OUT 98.60 98.69 Distribution Box IN 98.15 98.20 Distribution Box OUT 97.95 98.05 Lateral 1 HIGH 98.40 98.31 Lateral 1 LOW 98.40 98.34 Lateral 2 HIGH 98.40 98.33 Lateral 2 LOW 98.40 98.33 Lateral 3 HIGH 98.40 98.33 Lateral 3 LOW 98.40 98.35 Lateral 4 HIGH 98.40 98.35 Lateral 4 LOW 98.40 98.35 Lateral 5 HIGH 98.40 98.36 Lateral 5 LOW 98.30 98.36 Lateral 6 HIGH 98.40 98.34 Lateral 6 LOW 98.40 98.35 Lateral 7 HIGH 98.40 98.31 Lateral 7 LOW 98.40 98.36 Lateral 8 HIGH 98.40 98.34 Lateral 8 LOW 98.40 98.34 Lateral 9 HIGH 98.40 98.34 Lateral 9 LOW 98.30 98.34 Page 3 of 3 �1 TOWN OF NORTH ANDOVER+f °t NORTH 1 Office oft�6MMUNITY DEVELOPMENT AN6-kRVICES 3� �''�` � �" HEALTH DEPARTMENT 41A 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 s' s^1CHU5 Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: 0MAP: LOT: INSTALLER: �,(�_ �� �, �•, � DESIGNER: ,t, ez'Z"z�,HAZY PLAN DATE: E;5— BOH APPROVAL DATE ON PLAN: DATE OF BED BOTTOM INSPECTION: // /DOSC 41.0 DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION.- SELECT NSPECTION:SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SUMMARY FROM PLAN GALLON TANK = 6' I LOADING OF SEPTIC TANK GALLON PUMP CHAMBER = / LOADING OF PUMP CHAMBER = TYPE OF SAS = DIMENSIONS AND DETAILS OF SAS: SITE CONDITIONS ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer Comments: ❑ Topography not appreciably altered Page 1 of 4 TOWN OF NORTH ANDOVER E NORTH Office of"MMUNITY DEVELOPMENT ANIS 4ERVICES c',. ° ,' 0 HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 S4CHU4t Susan Y. Sawyer, REHS RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX SEPTIC TANK Bottom of tank hole has 6" stone base ®� Weep hole plugged ❑ gallon has been installed (H-10 o H-20) (monolithic or 2 piece) ❑ Water tig ess of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) 0� Inlet tee installed, under access port ❑ Outlet tee (gas baffle or effluent filter) installed, under access port ❑ inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed (H-10 or H-20) (monolithic or 2 piece) ❑ Inlet tee installed, under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off float working ❑ Drain hole in pressure line ❑ inch cover to within 6" of final grade installed over one access port ❑ Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24 hrs ❑ Hydraulic cement around inlet & outlet Comments: Page 2 of 4 r Yb x, S ? g q i Y v, , � fir;; ��� »� �•��� � s ` �' W 3 � wY S x 4 � i =«sr t"4 ONO gy NOVA w-• �c w 17 x NINE ,. ,. �' 11 .E Y f Aw 94 AW WK , � i Page 2 of 2 of t 3 •, I h E,Sr II r t .Mc v u a �a. 'a 3 � � T „arc ,t* c. y 11/10/2005 �1 TOWN OF NORTH ANDOVERf pORTh Office ofV6MMUNITY DEVELOPMENT ANIS-SERVICES °'' "oma HEALTH DEPARTMENT 400 OSGOOD STREET 411. NORTH ANDOVER, MASSACHUSETTS 01845 � °•arm �• 9 S'CNUS! Susan Y. Sawyer. REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX D-BOX ❑ Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution Comments: 11Speed levelers provided (not required) SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand.installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ laterals installed and ends connected to header (and vented if impervious material above) ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravelless disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Comments: Final cover as per plan PRESSURE DISTRIBUTION ❑ inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ Comments: orifice size inch as per plan Page 3 of 4 OWN OF NORTH ANDOVER r Ot NOR7H 7 Office of�--OMMUNITY DEVELOPMENT ANI)-SERVICES ,�?•_''"tD. ' A HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, ;MASSACHUSETTS 01845 S1CHU58 Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Comments: Rated for exterior if placed outside SYSTEM ELEVATIONS Benchmark: Rod at Benchmark: Height of Instrument: INVERT ON DESIGN PLAN ELEV TOP OF PIPE INVERT ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN D-Box OUT Manifold Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Page 4 of 4 x ¢ VN } p oHVreal f ,Y ,,M Block Lot p #a r 'errnis��orlis hire d.: > ares ` "toepuandzdual Shwa sal Sn A f PL Nb a46 ;, ` + U, vvi ogthe ppltca io di IS tISa z# ions Issued On % •,, �� ,.. sc kz ��°�g#{�t` �x � xis#v�afa-ri �� ��p :,�*�t 5 �y.° /} � ,�y �` jj .' '°�` t +3 ",• B" �i�' �Boad 0 Ca�t11 f ■��t��'���j�Y�lll���� £�R��,Ijti��l���ift �■Y��/1tf/ A� 0OaT' �ti lA lication 6r Se tic Dis oral S stem TODAY'S DATE Construction Permit - TOVN OF NORTH ANDOVER MA 01845 $ 250.00—Full Repair �4Ss�CHUs Key ' $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 ❑ Repair or replace an existing system component cursor-do not key the return A. Facility Information Y q �* 121 Litt� A q-AyY-n.w LIworz rab Address or Lot# /\/6 CLN &/Vb 0 C9 I?-V_ e'n City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) 'Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present) S.A.S. 2. Owner Information w- N nl a-'lam Name q6 R_f�r L I&CS ! 7�)V F-n--,c Address(if different from above) N- la-Nb 0 L'L tiv\'_ o City/Town t Q�Ll'5 State Zip Code Telephone Number 3. Installer Information (� e9 IA VV rUP� P F—A- -c V1- �� C f1 r VLC-t _ �p ASCI h�, d�. Name Name of Company 1IY4 ?/-�-(L Address City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information 0 Name Name of Address I\lA9.w `Z©-5Tam e 3e 70 City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 of µORTy Application for Septic Disposal System t,Oto '°7q'O TODAY'S DATE ° - pConstruction Permit - TO" OF 40 W1 ORTH ANDOVERMA 01845 $250.0-Full Repair , �gS �cHusEKa $125.00 -Component S PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction 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, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attacbed? • Yes No 2. Project Manager Obligation Form Attacbed? Yes4 No 3. Pump S sy tem? If so,Attacb copes f Electrical Permit Yes_ No 4. Foundation As-Built? (new construction ronly): Yes_ No (Same scale as approved plan) S. Floor Plans?(new construction only): Yes_ No Application for Disposal System Construction Permit-Page 2 of 2 r l� % INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 47 G �-' –41 Lei 1!J)A- I–AU Kvir, relative to the application of�y'-.> %KkNltdiffed '`3"4bF for plans by SoeLs+�h1tt4 U5i,,w7and dated 3 –�,_0 S' with revisions dated 5— S^ (5 o�' I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection – Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade–Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic staller GCi✓ Date: Town of North Andover 1 ; HEALTH DEPARTMENT 27 Charles Street North Andover,MA 01845 978.688.9540 healthdepOylownofiiorthandover.cont SEPTIC PLAN SUBMITTAL FORM DATE OF SUBMISSION: 3 405 SITE LOCATION: L, (`VE 1� 1 "17vow-evzn Uqv�-e ENGINEER: 90 1- vy-)NA' P,S Ip O SSM �� NEW PLANS: YES $225.00/Plan Check#: (Inc u es 1 P and one Re-Review Only) REVISED PLANS: YES S 75.00/Plan Check#: RECEIVED SITE EVALUATION FORMS INCLUDED: YES NO MAR 2 1 2005 LOCAL UPGRADE FORM INCLUDED: YES NO TSALTH DEPARTMENTER H �vJ6 S✓nyT�fi' S-01>-3VhY('o 2ETelephone#: ( OC Lt 8 7 2 Z`I(S Fax#: (y 0-�> �.�� 2--2- E-mail:- -mail• S 0\ S VM v}-Al Q— OL . CO-.l HOMEOWNER NAME: OFFICE USE ONLY When the submission is complete(including check): 1. y Date stamp plans and letter 2. SonWlete and attach Receipt 3. 7/o File•Forward to Consultant taut 4. Enter on Log Sheet and Database 970GGIR476 HEALTH �1 PAGE 02/04 TOWN OF NORTH ANDOVER 0 k 0frce of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STRUT NORTH ANDOVEK,MASSACHUSF.'M 01845 ±, SUM a Y. Saiz ay.REH3T;:S 97$.689.9540—Phone Public HwIth Director 978.68$.9542—FAX Aprd 25, 2085 0 Douglas]. Smith, R.S. SoBrnith 15 Fox New Boston. NH 03o7d3 of Na`�P RE: 46 Raleigh Taverne Zane,North Andover, MA Dear Mr. Smith, 11e proposed septic system design Platt for the above site locatlon, dated 3/3105 and received on March 21, 2005, has been reviewed. Unfortunately, it content be approved until the foilowing items rare comccted. Each item is followed by the sped section in Tide 5: 310 CUR 15.000, or North Andover regulations which is not met by this design. I. It is unclear what is specified for the assessor's map and lot mnuber. Please+clarify the number currently indicated as"210 107A►'. 2. The design LTAP.used for the prirhe leaching area is inwrrect. A-,-slue of 0.7 was used(Class 0 where a value of0.6 should have been used based on the soil texture of tt±e most restrictive soil layer(Class Id-Sandy zoaan). —242(1) 3. Trenches should be used where ever possible. Please provide a design using trenches instead of a field or explain why this is not Bible on this site.-240(6) 4. Regarding the profile, please provide the following items_ —220(4),NA8,02 a. Mstirig grade should be drawn as a time nming through the length of the entire system. b. Finish grade elevations over the septic tank, d-box,and Soil Absorption Systeme !/ (SAS)should be stated. c- Estimated Seasonal Hlgb Ground Water(ESHGi)elevation should be stated. (/ d. There is less than 9"of cover shown over the tank. 5. The site plan must show all of the distance between the building and the SAS and [/ distance between the septic tank and the property line.NA 8.03 a-e 6. A,North arrow is inissing. -220(4)(S) C� 'Cie,5 1E.: 3 J7868884' HEALTH �� PAGE 03/04 y T. Elevations are not given on the proposed contour lines around the primary or resenrazl_---'- areas. -200(4)(8) If the contours are at 2' intervals,they do not meet the 3:1 (H:V) grading inquire ts. -255(2) If the contour around the primary SAS is at EL 98, there is not 15' horizontal distance to breakout of 48.16. 8. The note on the cross section states: 6"washed sand under system. This note should zl� be clarified, as it is in direct conflict with note 10. Also, significantly more than 6" of salad will be needed for the septic system to be 4' above the ESHGW. 9 Note 10 should state that soil removal must occur 6"into the naturally occurring material.-NA 4.02 lBascd on ESHGW Elevation of 93.40 and bottom of the SAS Elevation of 97.25, only 3.85' separation to groundwater is provided. [Design note. Since the currently proposed slope of the building sewer is at the minimum required 1%, it appears the building sewer will need to be raised at the foundation or a pump and pump chamber installed after the septic;tank to meet the requited groundwater separation.) l l. Existing septic tank location must be shown on the plan. A note regarding proper f/ abandonment of the septic tank is also needed. -354 12. The depth of cover material over the leach area must be specified. The requirements l/ ,ire a mirimuro 1"'(9'clean backfill plus 3"topsoil) and a maximum 36".-221(7) t;. Regarding the building sewer,the following details must be stated on the plan: a. Pipe diameter(A"midmum).222(.1) v y. �Warer tight joints. 222(3}&(4),NAI 1.02 c. Pipe laid ott a compact, firm trace.-222(5) d. Pi*e laid on a continuous grade in a straight line.-222(7) '14. Regarding the effluent filter(refer to the Massachusetts DEP approval letter for the c/ selected filter for additional details), a. The note on the plan states the filter will be installed in the tank outlet. It:should say "outlet tee" or some outer more appropriate description. h. The filter t peI.name should be stated on the manhole cover. c. There should lie a filter maintenance schedule specified. 5_ Regarding the septic tank, the following specifications need to be stated on the pian: 228(l), (2), 221 (8) a. One child-proof manhole cover mast be constructed to within 6" of finished grade b. The location of the access polrt(s)which will be fitted with a riser(s)must be specified c. T.be stone beneath the tank.must be specified as 16. Regarding the distribution box.notations are needed for the following: i. Outlet pipes laid level for the first 2 ft.-232(3Xc) ii. Stone beneath shall be<= I '/z" .-221(2) y r n..1 H�.AL i i ". :�l�c r rdiz�g the distribution box, there it only V between the edge of the box and chaFriuers. That will likely not be enough space for the multiple pipes and bends F eg iding the placemen of the soil absorption system, what ,s depicted on this plan is Cf Mot w"tat was discussed in the:fieldtouring soil testing, it was noted that extensive fill riawrial was encountered in Test Pit 3 on the side neer the driveway. It was decided at that time that:the field Would be sited away from this area, nearer the center of the yatd. Pleme submit an application kbr additional soil testing to be performed in the locatio, of the soil absorption system proposed on this design plan. A,ttematively, you n sasti ,- it3 slet to inove the soli absorption system to a location encompassed by the OdFtp;19 test gaits as was discussed in the field when the original site evattiation ?cc-ut d. plear depict the location cif the wetland resource areas on either side of this parcel, !t1 5��"FF`.� tl3C C4tthCtt tion c�fthe Cons m. ation C:orartission with this delineation, and ind;ca€e the elate of their endn.-semens. to ':6Jntact the office any questions you.may have. We look fotwand to :,-;g -.oath YOL to obtain a wptic system which will be in crrntpliance with all regulations ud 1S3tFr,' rc�tec�i rr, of public ,'.ealth and the envirowne€nt of North Andover. Y'i1E7fFt'; : lth.Dimetor cr, `;wFaer @A'�'7M DESIGNS 15 Foxberry Drive �7V New Boston,NH 03070 (603)487-2298 J. (877)487-2298 Toll Free Email:soilsmtih@aol.com May 7,2005 Attn: Susan Sawyer RS North Andover BOH _ 400 Osgood Street RECEIVED North Andover Ma.01845 Re 46 Raleigh Tavern Rd. Septic Plan MAY 0 9 2005 Dear Susan: TOWN ur lvuRTH ANDOVER HEALTH DEPARTMENT I addressed the items on your letter dated April 25,2005 Enclosed are 3 revised copies of the plan,a copy of checklist and letter. #1 Assessor's map and lot#have been Corrected #2 Design size has been changed to Class 2 0.6 value #3 Trenches are not feasible on this site. In order to provide the separation required in between trenches the area is so large that it extends the system over unsuitable areas based on soils and topography. On this site I believe that a more compact footprint as I designed results in placing the system in a more suitable location. #4-7 These have all been addressed #8 The washed sand note has been eliminated #9 The 6°soil removal note has been added on the plan #10 The elevation of the bed is now raised higher so that it is 48°above eshwt When they remodel the house they sill raise the sill height accordingly. #11-17 These have all been addressed #18 The system has been re designed to be over TP 4 and extending across the front yard as discussed in the field. #19 1 will delineate the wetlands on all sides of the property ( I now have permission from the abutting property owners to enter their properties to perform this task). I will submit a separate plan to Conservation as these areas wont,fit on this septic plan. Please call if there are any questions. Thanks Doug Smith rZ S Soilsmith Designs rg 1'P P RECEIVED C14ECKLIST FOR NORTH ANDOV1ER 0 9 2005 _ SEPTIC SYSTEM)PLANS MAY Job '` OVER TOHEA,TH HEPAR MENT Thv fullowin is,i cl,ecldist that incorporates all Title S and local w-ulations'f re plans. Noun of App:scunt _ �h�L Name of Designer: SYlr1 Plan Date __.. _- Envision late: Data oFlteviewJ�:� Property Adifrc5y: .._� ..r,__ Map:.JQ2 V! Lot: 8014 Reviewer:_ -____.-._..___._..- ,._ Type of P Number of Be;dreorars: __- apd} Garbage Disposal,Allowed: [General Info rniatit)n: N.A. =North Andover Septic Rqul ations Other numbers res;.to Title 5 OK Problem N,"A r/ -__ Street number and maphot-220(4)(u) MtLki tum scale of i "=40' for plot plan- 220(4) NMaximum sc.:aiv-of't "=20'for profile and component dotafls-220(=1) 'L�C _ _ 1 :hal bowidaries of the facility being,served-220(4)(a) ?Names of abuttorb:tom recent tax nup- NA 8,02j _ Number of bedrooms,design cafes., -NA 8.02i Name &address of record owner&applicant- NA,3,02k Name&.airiness of designer -NA 6.021 )-folder'and location of ell uasetnents-210(4)f b) bate plan drawn&any revision data- NA 8.02rn All dwellings rind buildings,existing and proposed-2200)(c) Lox mien of all existing or proposed impervious areas-220(4)(d) All distances on site plan,-NA 8.03&-c Llevatinrt of proposed driveway-NA 8.02t t'10�e _.., Iocation and elevation Lit foundation drain-NA 8.02y Location rand dirntsnsions of the:system incl.reserve(new cont.)-220(4)(e) i_irnmi of excavation of(each urez on site plan-NA 8.022 Locus piar. -220(4)(t) (Not to scale] North arrow ..220(4)(1) Existing and propuwd aoutours• 220(4)(8) _ Locations and togs of sleep holes-220(4)(h), '-.ovations wid lops of percolation tests- 220(4)(1) bate(&)of scil resting-220(4)(h)&(i) Existing grade elevation of each deep hole-220(4)(h) Elevation:of percolation testa-N.A. 8.02n _ N:unc Of approvrng authority representative -220(4)(h)&(i) Naine of.soil evaluator-:220(4)0) Stihl logs and pare test logs match BOH records t/ Locutions of waterh aes,drains,and sabsurfacr, utilities-220(4)(m) OSserved:and adjusted 8.w. elevation in the vicinity of tho sys tm-220(4)(x;) Complete profile of tlrc systerra to scale:-2120(4)(o),NA 8.02e ~� Cfoss section of leaching facility-N'A 8.02w (No( to sack) Location of bunchrnark(�) within 50-15'feet of facility -220(4)(q) rA Note listing all variance reduests with proper citations-220(4)(p) Loc,tl upgrade;approval roquost form submitted-403(1) Hi-lti3H 91170389BL6 Gt :SL S00ZIZZ!70 2 Uriginu R.:i P.L.staml), signature&date-220(1)&(2) n.a PI.,discipline specified within sump. MGI.C. 112 s. $t M sfc. supplies(wha 400'),pub. walls(vr/in 250'),pvt. wells(w/in 150')-'120(4)( TU gt �fJo�e � � c `r rtioi;of wawrcourse wetlands volls,etc. w/in 150'of'systen)--NA:8.02( di3cluimer�-►\A B.O..s RLS plan reference &certification required (prop line setbacks) - 22.0(3) Flan crinmins designer's certification slatemettt Use approvals/standards checked for I/A SyStem-DEP does., X10 Porc rate>30 MPI-not atlowod for new,LU.A for upgrade-2450)&('31, rate >60 Mpt-rrwt use modifted tilght tank car!/A rechnulo8y-245(4) r'roposed sJstem qualifies as"Shoved" systrm-002 (definitions) OLA Flow is over 2,000 gpd-No R.S.allowed-220(1) Design flow waiF, set in accordance with code-203 1� Existing systean location and note,on proper abandonment-354 L1 1 4 oathit4g facility at least V above base Flood elevation—NA 9.05 All piping Sch 4IJ minivautu—N.A 10.01 Basement Iluor inlWutum i' slxwe groundwater elevation—NA 5.04 F-.)undatOn lain present with elevation-•NA 8.02y On-site Soil and GIrou d ffAe ReyYeWv OK Problem NI? — v Proper steep obsorvration hole togs on plian-220(4')(h) All deep holes and peres shown,including aborted tests—NSA 8.024: Soil evaluation fornis eubmitte}d within 60(lays o1'lfeld work-018(2) Prober pereolKtivn test log-220(4)(1) v Ample detp observation holes hi primary disposal ares(minimum 2)- 102(2) __-_._._ ✓ Ample deep observation boles in secondauy disposal area(minimum 2)• 102(2 i _..L/ -Ample pert testing Gane in each disposal area, 3 in prim.>2,000 gpd) - 104(4) Deep hole testing conducwd within two yeius-NA 7.05 Hole Identification Numbers: ground elevation el. acceptrlbic sviI e,;1 Ltach Facilit• invert el. ground Nater ti, resiusal et. nottom of leach facility el. thickness of acceptable soil before&after*oil R&R separation to grQundwatel' sepac'ntion to rstctsal soil class __,._�..... Z Hl-Iti3H L 90Zi�". '''4z/b0 1 Pere rate -_._— loadiltg tett _— yeptic tank Below o w. t��ble _ _____r� ('yes or no) nu:rp reale beio v ow..table (yes or no) 11 in Pili _._ -255(l) Seblack Dlbtaances(Given in feet) 15.'21 1 YES NO is the lot in the Lake Uacttiewick 111r'atershed7 NA 6,00&5.02 OK Pro irm N1A Septic Tank Leach Facility Property litre W 1U .:-Ilia wall 10 20 toground pool 10 20 Slab foundation 10 10 Duck,on footings,ow. 5 10 waterline 10 10 Private drinking wr11 75 100 _-_-- Irrigation well 75 100 wetlands 75 IOD Public:well 400 400 Wetlands bordering surface 150 150 water Supply or trio. (in Watershed) _.... _ Trib.To Surface Water supply 325 325 ___ _ 12eservoira 400 400 "tributaries to reservoirs 200 200 Drains(war. uppiy/trib.) 50 100 DfL ins(intorcept U.w.) 25 50 l-oundation drains 10 20 _--- Drains(Uthw) 5 10 _-- Drywc lis ?0 25 Downhill slope 15'to 3:1 slope 3 T«1a IC)Ftrl H.LIV3H 94088896L5 9T tG /Z,Z V6 �J w/o barrier Building S V r OK Problem N/A _ JMOf� Grease trap rcgt rcd for cerasin uses(chuck 230 for details) Pipe diaimtor listed(4" minimum)-222(i) Pipu schedule listed Pipe cast iron or ch 40 PV~-NA 11,02 Watertight joints sped le -222(3)&(4) Pipe laid on compact,tui base•222(3) (�Pipe laid u►t continuous grade in straight litre-222(7)0 �Jy .�ypj Cleanoats precede:all changes in alignment and grade-222(8) Y Cleanout provided every 100 feet-222(8) p Manhole at any 90 degree,alignment change-222(8) Invert elevation at building: _ v Invert elevation at septic tank! ---."L R_ __.Se" Ungth of run: twe �Slope, ,,_ 'imurn of 0,01 0.02 desired)-222(6) 1u'offset to privateor suction tae- 222(2) SeRtic Tank OK Problem; N,`A __ _ _.__„__ _•�� Tank is accessible-228(3) No structuMs Uhove tank—(228(3) _ Tank can accommodate both primary&reservt—NA 9.04 200%of flow(required&provided given. 1500 nun.)-220(4)(f) &223)(1)(a) 2-3” drop froin inlet to outlet-227(5) Minimum of 4'liquid depth-223(2) 3"air space above tees/baffles(adaintum)-227(4) 9"air space above flow line(minimum)-227(4) 'lets are not to be replaced by baffles-227(l) t�"Cees extend 6"above,flow line-227(!") Inlet tce 4�xtcnds 10" below flow line(tminintM)-227(4) _ t*✓ Outlet tee extends 14" below Vow line(mury for deeper Links) - 22 7(6) --L,"-Gus battle installed on outlet-227(4) Access manhole cover above center of nark&each tee:(except 2 eornpart) ;2''2 8(2) ✓ 3-20" manholes-228(2) ��/ 1 childproof.24" riser/ttaanhule wAn 6"of final grade if<1000gpd- 228(2) Tn!et and oulct tees on center line-227(1) S1 c -tion below tank specified(if soil is non-native)-221(2) 1`1, __-__ _✓ 6" <-314"s ne beneath tack.specified-221(2)&22 3(1) t_e�rlet2 S`ted not a single fang.dwell.muat be 2 tks or 2 comp--223(l)(b) !-.� ✓ If plan spociiies disposal must by 2 tanks in series or 2 compact.tank- 223(1)(c) _,3JA 8uoyranCy c•dlcs,required if tank at or below water table-22 1(8) -_y_ Tank is watertight-221 (1) 9" of cover over tank(rrrinirrrum)-228(l) �r il- 1 U loiAing(ruin.) -H-20 if traffic- 226(3) I*op of tack<-36"below grade•?.21(7) „_. !dA Ali pumping to tank(if applies) in accordsrnca with -229 AA Tank is set to keep old system in service dizing install if possible 4 T/FA r)k+d H1-1V3H 94t�8869SL6 SZ :ST. J ``J Tight (Cheek here:1'not presrnt: OK Problem N/A _�._. I(l(13'o of design 1'1ow or 2000 gallons provided-260(2)(x) 3-20"manholes-221(2) Soil compaction below tank specified(if soil Ston-nritive)-221(2) r i b"of<=314"stone beneath tank specified-22l(2)&228(l) .L Buoyancy vales.Required if tank at or below water table-22 1(8) Tank is watertight.-221(1) 9"of cover over tank specifwd(minimurn)-228(1) -_. H-10 loading(thin.)-H-20 if traffic-226(3) ,� _•__ Top of tank« 36"below grade-221(7) All pumping to tack(if applies)in accordance with -229 AN alarm se;at 3/5 tank capacity-250(2)(c) MIn. 1.24" frame w/cover ut finished grade-228(2)(f) Year round access for pumping-22.8(2)(;,) Distribution Box (Ch"k,here if nut present: . ) 4K ProbL-ni N/A 2 Inlet elevation: _,_ I I ____- M—_ Nutlet elevation: 1) '17'drop from inlet to outlet(ininimuin)-232(3)(b) b" sump(minimum) -232(3)(eI L,-"-All outlets at stone elevation-232(3)(b) �Uutlet pipes laid level for first 2 ft.-232(3)(c) l�Pipe Sclt 4U- NA lU,U� r✓ `wnber of outktts: �-.�-�1- umber of laterals: Sire of outlets: inlet baffle/tee ruin. V over outlet invert for'all d-boxes- 232(3)(a), ___jZ toil compuction below distribution box specifted(!f soil is non-native)-221(2) b" of stone beneath distribution box specified-22 t(2) B ux is watertight-221 (1) Top of box<=36" below grade 221(7) Buoyancy calculations required if box is at or below water table -221(3) Puna Chamber(Check here if not present: __�) OK Yrt)hlc.an N/A Volume speciPied-� 220(4)(r) Pump on clovatio 220(4)(x) Pump off eleN'atibri: -- 220(4)(x) Aturm on elevation: 220(4)(r) Number of cycles per clay-220(4)(r)(also 254(1)(d)if gravity frurn d-box) MininturA"delivery line to d-box if gravity•254(1)(c) 1,ressusk dosed lI if flow>=2,000 gpd-254(1)(a)&254(2)(x) �_- CyV per day is consistent with chamber votuxxus-23 1 Vcrtume calculations include flowback volume -2') 1(2) i ,, ;ar -ar,rr-4 H1'I'd3H 9Lb8889BL6 9L:GL 3 ?!LLihO 6 ti4 hour storage capacity above pump on elevation-231(2) Ntrnber o'1'pumps: _ 2 if systatn serves>2 dwelling,unify-231(6) Capacity of pump(:;)- lgprn to TDH- 22.0(4)(r) Pump ran pass 1 1/4 "solids(minimum) -231(7) Primp controls sptcified - 220(4)(r) Alwin equiptnant specitiod-231(2) —__ Alarm is in building and powured on suparate circuit notn pump- 2) 1(9) Pump setluunce correct(off-lead on-lag on-alae-n.on)-231(8) Pump performance curves included-220(4)(r) Vla ual operating switch-I;A 12.01 Check valve,bleeder hole:-NA 1101 1 childprocf,24" riserintanholu to final grade- Soil compaction beneath pump chamber specified(if soil is non-native)-221(:') - - _ h"of<=314"stonti bunouth climbr.�pacifled- 221(2)&228(l), Buoyancy culculations if chamber is at or below waver table-221(8)Cw 9" of cover over chamber(Minime,tn)- 228(l) H. 10 loading(min,)-H-20 if traffic 226(')), Chamber is watertight-221 (1) Top of chamber<=36" below gxade 221(7) reaching Facility (gene: ul-complete for all designs) OK Problem N/i, k9 50%larger if garbage:disposal- 240(4) '� A, No _ - !'tenches to be used whenever possible- 240(6) e, No vehicle or imperv.area above It unless unavoidable-240('1);NA 13.021 Vented it'under impervious3,,ovL�r - 241 (1) VCllted through same pipes as distribution system- 241 (1)(a) v cnr pr�lt%cted'tkoin pfecipitation/animal entry-241 (1)(b) 11lentis placed beyond traffic or impervious ureA- 24 1 (1)(c) All lines connected to vent if bed or trorelies-241(1)(d) 9" cover over peastono-240(9) kuserve area provided(new construction)-248(1) Rese, .4' from primary leach aria-lv'f#9.OR W(5'if pert rate<=2 MPI)separation to g,w. -212(a)&(b) 4'(down to 2'with variance or 1/A-upgrades only)of tiatural soil under 11 _ d`L GW separation is adjusted to highest existing grade,if''acility cuts into a htlis:ac �J Ir � \S O Pipe slope trunimurr.►of 0.003-251(9) l R quire 5'removal and replacement:f in till - 255(5) Q� Top of-loach facility<z 36"t)ulow grade - 221(7) Final grade ovrt 11 ininimum 0.02 ft/ft 240(10) SUrfacu&subsurf ae,drainage away from Lf.- 240(1 1.)k 24.5(5) 1ni-If Nlimmurn de.sil n flow 440 gpd without deed restriction-NA 13.01 3-1 slope where grading requin;d- 2:35(2) 1,)r of Bill slope stops s'from proper' line or swale inytaLed-255(2) frnpermeable barrix if<3:1 slope or< 15 foot to--3:1 slope- 255(2, lmpernteable harrier/retaining wall poured concrete--ITA 9.02 Reuining wall stamped by P,8,.255(12)(b) nfi 'fop of retaining WW1�;.=top(if peastone elevation -255(2)(1) 10'aAUut fiom edge of leach facility to edge of ret. wall -255(2)(g) i'erc tert(s}Bono in rrloA restricirvv,layer-IU4(2) P,-rc test 4' below leaching elevjtio.n-NA 7.06 ;0esign i'low listod and required/provided leach aroa given.220(4)(1) Leach pipes SO-140:PVC-NA 10.()1 ?.each pipes ninirnuni 6t" diamoter except for dosod system-NA 14.04 b �rT -:1LM.4 H1-N3H 5108889©16 9T :ST 9007.. ZZ t't? 1 r 7 IJ Leachlijle6 ;ip Ated,or eor:neemd together 25.10 Pft&SUTC dosing 9141daSlc;ti'followed if pressure distribution 254(2)(c), _..._�.. .. V� Pressure douina reciu red Over 2.000 gpd or with 1%A remedial use-23 t(1) Leachirm Trenc hO(Chvcic here:i1',sat present:_ OK Problent 'N/A Number of teen,hes;—_ Minialum of 2 trenches-'NA 9.0:(2) Npth of trenchos (max eff. 2');_---_ 24'I(i Width of Lranches(T ruin-W max)' 25:1 (1)(33) Length of ktrnahas(iDO,rtirx.): 25 1 Trenches arc veined(whim>50')-231 (1 1) "!'reaches ['ollow contour fines-251(2) Trenr..h spacing 3 times effective width or delO minimum-251 (i)(d) In till cr roserve betwoon trenches, 10' ruin. -NA 14.01 nr 14.03 �.vailable]each arca elven(Min. 5010 s.i:; •NA,9.01(2) Sidev;all=L__-- x D z!# _x 2 leach areft givetl __-_ --- Loading -__-,-- �___ Effective wea=total ui oa_ s.f. x I:,TA1i Effective are; is>=dasign flow of ac,lity being served 2"of 1/8" 112' 2x washed,pcustone. 24'1(2) Trea:rh depth of 3/4" P.o 1 1/2" doublr.wa&he3 stone-247(L Lu Chin PIr<4(Cheok.h .s° it not present: _ OK Problem N.A. #of pits/pit systems: (dosing chaniber if t,231 (1)) Dimensions of each pit or system:L _.W--- D Depth of pits(max off, 2'); _ �.-_• 253(1)(ii3 Avuilablc mach area given 0 attom=L_ _ ..__x W x*of systems __. s t ------- r. Sidewail m I.+W..- x D_ __.-_- -_---_--_ --�-- i oral area a bottom w + iidewali .-._...._. Eff etiw leach area sivc.P. Loading factor,_,_. .Ef oCtivo stmt- rota]area s.j. x 1.'TA10_, = g/ddy Effective area is>=design flow of facility being se'r%,Ld 1Vli.aitnuin of 2 pits at least 13'X16' NA 9,01(3) Distribution for ga teriss/chmbrs.in Lrew.h;;olid-. -pipe every 2D -253(6) Distribution for galleries/ahrribri. in bed config.-ea.pipe serves <=40 Spacing-2 times the offecdve width or depth(the greater)-253(1)(e) T'of 1/8"- 1141" 2x washed paastone,-247(2) 3/4" to : 1/2"double washed stone-24?(1) Euich pit has at least une 20" access cover.24" C1 to grud.0 over 2,000 gpd 253(3) Surrcunding uggruga:te thickness belwoen ]'(nun.)and 4'(rY1ax.) - 253(l)(1) Vents, if necessary,extend under covers of pit(s)-241 (eI Leach Fields(Choc!:Jlere if nut preseut: OK Problcni N/A Number of fields-, ____ ('need dosing chamber if> 1.23:1 (t?) r C,? 17r IC)HA Hilt+3H 9Lb0899OL6 91 :Sil Length 00u 50 5z(,-))(b) Width: rol3S ratal ao%-L x W Minimum WO squue feet-NA 9.01(1) DOitribution lanes connected wM solid pipe,–NA 15,01 Effective leach area given Loadln#factor._—., Eftee6ye area=total area --- s.f x Effective Area is>:;design flow of tacillity being served minimum 0'1 two distribution lines-2.52(2)(a,; 6'fine.sovaratiol,(njux)-252(2)(d) 4'maxiinwn separation frQiu edge of field w linu-252(2)(e) 10'rniniumnseparation between adjacent leacb fields-252(2)(1) Bvtween 6"find 12" of 314- 1 1/2" stone beiritath field- 252(2)0)be 247(2) 2"of 2x washed peastone,247(2) Final OK Problem 'S!A Slope;over leach area minitllun)of(1.02feet/foot—240(10) !/ Grading shall divert drainage away from lauch area—74.0(11) Gradifte,slopes away from dwelling r H.I.IV3H 9T :91 'TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES h � A HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 CHustt Susan Y. Sawyer 978.688.9540—Phone Public Health Director 978.688.9542—FAX May 13,2005 Bob Bennett 46 Raleigh Tavern Lane North Andover,MA 01845 RE: Subsurface Sewage Disposal System Plan for 46 Raleigh Tavern Lane,Map 107A,Parcel 106,North Andover,Massachusetts Dear Mr.Bennett, The North Andover Board of Health has completed the review of the septic system design plans,for the above referenced property,submitted on your behalf by Soilsmith Designs,dated March 3,2005,last revision date May 5, 2005.Received by the Health Department on May 9,2005. The design has been approved for use in the construction of an onsite septic system for a 5-bedroom(11 room) home.This approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work,and a Certificate of Compliance must be endorsed by the installer,designer and the Town of North Andover. This approval is subject to the following conditions: 1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void,installation shall stop,and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 2. It is the responsibility of the applicant and/or the applicant's septic system designer,septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission,Zoning Board,Planning Board, Building Inspector,Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Your effort to provide a properly fimctioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincere', usan Y. Sawyer,REHS/RS Public Health Director cc: Doug Smith,Soihsmith Designs file CrOWN OF NORTH ANDOVER of NORTH 1 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET41 10 NORTH ANDOVER., MASSACHUSETTS 01845 C«usk� Susan Y. Sawyer 978.688.9540—Phone Public Health.Director 978.688.9542—FAX October 31,2005 Bob Bennett 46 Raleigh Tavern Lane North Andover,MA 01845 RE: Subsurface Sewage Disposal System Plan for 46 Raleigh Tavern Lane,Map 107A,Parcel 106,North Andover,Massachusetts Dear Mr.Bennett, Upon application for a Disposal Works Construction permit,by Mr. Warren Pierce,it was determined that due to relocation of the new house foundation,major alterations to the approved plan must be made.Mr.James Kavanaugh submitted a plan on October 27,2005. It must be noted that Mr.Kavanaugh has replaced the engineer of record.The North Andover Board of Health has completed the review of this revised plan. The design has been approved for use in the construction of an onsite septic system for a 5-bedroom(11 room) home.This approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work,and a Certificate of Compliance must be endorsed by the installer,designer and the Town of North Andover. This approval is subject to the following conditions: 1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void,installation shall stop,and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 2. It is the responsibility of the applicant and/or the applicant's septic system designer,septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission,Zoning Board,Planning Board, Building Inspector,Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincerely S Y. Sawyer,RENS S lic Health Director cc: James Kavanaugh,P.E. Comments Date: 10-05-2004 Peter came in to the Board of Health,representing the owner of 46 Raleigh Tavern Lane and met with Susan Sawyer,to discuss an addition to the house. After review the Board of Health determined,that the Septic System is OK for a dwelling up to 9 rooms. TOWN OF NORTH ANDOVER �f of NORTk 9 Office of COMMUNITY DEVELOPMENT AND SERVICES • HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER,MASSACHUSETTS 01845 "S�AGHUs s`g Susan Y.Sawyer,RENS,RS 9'18.688.9540-Phone Public Health Director 978.688.9542-FAX healthdept @ townofnorthandover_.c_orn www.townofnorthandover.cor APPLICAT40FOR SOIL TESTS DATE: _ MAP&PARCEL: e-LOCATION,0V SOIL T OWNER: ��i Contact#: APPLICANT: ontact ADDRESS: / (/! ENGINEER:<'{�y Contact#: / /d c a�- .S1 CERTIFIED SOIL.EVALUATOZ: Intended Use of Land: Residential Subdivision Single Family Home ommercial Is This: Repair Testing:__._ Undeveloped Lot Testing: 'pgrade for Additions_ In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM Proof of land ownership(Tax bill,or letter from owner permitting test) ➢ 8.5"x 11"Plot Plan&Location of Testing(please indicate test nit sites on the Plan) ➢ Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$360.00 per lot for rea rs or upgrades. GENERAL INIFORMATION Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. ➢ At h.a,t two deep holes and two percolation tests are required for each septic system disposal area. A Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH representative. ➢ Fuli payment will be required for all additional tests within two weeks of testing. ➢ Within 45 days of testing,a scaled plan(no smaller than 1"-100')shall be submitted to the Board of Health showing the!,-)cation of all tests(including aborted tests). ➢ Within 60 days of testing soil evaluation forms shall be su°,mitteel. Please Do Not Write Below This Line N.A. Conservation Commission Approval Date: Signature of Conservation Agent: Date back to Health Department. (stamp in): 1r\ruvorur\rurvu MmbuuKLtb � 1y'(d4'(b0b24 NO.356 D01 Cj `J Robert B. & Eugenia A, Bennett 46 Raleigh Tavern Lane North Andover,MA 01845 Tei: 978-688-1238 January 10, 2005 JENSEN DEVELOPMENT Corporation 37 Porter Road Andover, Ma.01810 (978)475-0565,fax: (978)475-0524 Peter=ave Dear Mr.Jenson, With this letter we give Jenson Development Corporation and its sub-contractors permission,to dig test pits for the purpose of designing an upgrading your septic system on our property at 46 Raleigh Tavern Lane,North,Andover. Sincerely, Robert B.Bennett �_� . Eugenia A.Bennett iolr se�., c }Qt�--J�►K�' 10 Andover, 1`�assa�,fzuse��s �'ey� wed,bald.��-�eY4f *q73! 2,49.57 h 'i 4v RALZtC�-k TAYERt4, LAKE i hey-e6� Cer'�-t't _�hz� '41i4S toe a*Ion sur+/eY w 2,s trtade 6 me an 4 e_ ?f-ound : ani 4� ;;4 �6e dweti1'rzq '564wtc is laca�ed cm 44,c (of ap p-ax � .a- �1•� as �t4-i-�ec� , and 46i-� -+e Towr oi�T�i Arlfl4 t=t� anc� �riz� � e �a-� meets e <o�trtG ar +he a.,cecs-aii l Tewtt.. Pto+ Pt art orgy - G`%�Q2iV 7. 7. 7C. Dellechiaie, Pamela From: Pam Dellechiaie[pdellechiaie@townofnorthandover.com] on behalf of Dellechiaie, Pamela Sent: Wednesday, February 02, 2005 2:57 PM To: 'Daniel Ottenheimer(E-mail)'; 'Lisa LeVasseur(E-mail)'; 'McBrearty Andrew(E-mail)' Cc: Sawyer, Susan Subject: 46 Raleigh Tavern Lane-Status of Soil Test Importance: High Sensitivity: Confidential Hi, Can you let me know the status of this soil test? Please note that Steve Durso is no longer the engineer. The new contact is: Doug Smith -Soilsmith Designs, 603.487.2298. Please call him to arrange any scheduling at the site. Thank you. 1 { i � � � • } . � X65 a , Y R Pr IF. t ;. f � t • t f f - w'1 B ` I �I \-41 SPS-,v5 �� o+°oj \J ��� ,•r•sstirw b(S t,S'2 �S �� ©�i'bZ I � � � ; -1 S 11-O rS bh r c�j tgpmo 1 ApC) �'b Q AAL nor,, (o /,.l al fy S � I LI . .z^t*S lz f LS Avis Ls+va (vo '00;0 t Mod 4VIS L-a r ,-,,� fib._p �`�� � d ► �►1�^G y assachusetts Department of Environmental Protection �.. Bureau of Resource Protection — Wastewater Permitting Program (Q ��l1Lt� —��' !— '` Form 11 - Soil Suitability _. mer �___ ' ty Assessment for On-Site Sewage Dis osC A. Facility Information 1. Facility formation ` MAR 1 2005 Owner Name — TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Street Address Lea �'�1'P Map/Lot �d (�'7 aty o4 V1yl V-1C7\ �? y � 1 State Zip Coe B. Site Information 1. (Check one) New Construction [ / Upgrade P9 ❑ Repair ❑ 2. Published Soil Survey available? Yes [6/No ❑ If yes: _ I 1----�_— I s 8110 Year Published Publication Scale Soil Map Unit GoY,7plSoil limitations3. — Surficia! Geological Report available? Yes ❑ No E4-"�_If yes: Year Published ---_----- Publication Scale --------- Map Unit--- Geologic Material Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes ��, / L�-Y No ❑ Within the 100 year flood boundary? Yes ❑ No [� Within the 500 year flood boundary? Yes ❑ No Within a Velocity Zone? Yes ❑ N o 5. Wetland Area: National Wetland Inventory Map Wetlands Conservancy Program Map Map Unit Name Map Unit Name 6. Current Water Resource Conditions (USGS) Month/YearRange: Above Normal ElNormal [Below Normal ❑ 7. Other references reviewed: Massachusetts Department of Environmental Protection 1� �., Bureau of Resource Protection — Wastewater Permitting Program Site Address or Map/Lot Nurnber - Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal p C. On-Site Review (Cont.) Deep Observation Hole B: 74M_os g_1S _ Date Time Weather 1. Deep Observation Hole Logs Deep Hole Number _ Ground Elevation at Surface of Hole .. 10-2=Q 5 Location (Identify on Plan ) _ Yjua, C, S) CA e 2. Land Use: jr es rG� � h c7 (e.g.woodland,agricultural field,vacant lot, etc.) Surface Stones Q Slope (/o) Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body Vl Drainage Way h_ D� Possible Wet Area _L�C feet, feet feet Property Line— � Drinking Water Well t!'?O�e Other feet feet 4. Parent Material — �1 Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s)❑ Weathered/Fractured Rock❑ Bedrock❑ �J 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit DI epth Standing Water in Hole Estimated Depth to High Groundwater: 1 �✓ .3>inches elevation Massachusetts Department of Environmental Protection Bureau of Resource Protection — Wastewater P ermltting Program Form 11 - Soil Suitability Assessment for On-Site Se Site Address or Map/Lot Number Sewage Disposal Deep Observation Hole A: Deep Hole Number: Soil- - Soil Matrix: - Redoximorphic Features Soil Coarse Fragments Soil Structure Depth Horizon/ Color-Moist (mottles) Soil (In ) Layer (Munsell) Texture % by Volume (USDA) Consistence Other Depth Color Percent (Moist) Gravel Cobbles 8 Stones -I(o I o��Z3t3 T-,YN e Z`�'`� Sao ; s-,n�� - /$ / Lr o Yn1 Additional Notes Massachusetts Department of Environmental Protection y 9V-31e&%� 1 Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number Uv"C Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole A: - C)o S Dat'L�S S Time Weather 1. Deep Observation Hole Logs I 1 Deep Hole Number= Ground Elevation at Surface of Hole t 0 Z1 � Location (Identify on Plan ) hy) 2. Land Use: _ 1/l2 S 1& ww��_ Az_ O (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body h_�� Drainage Way h Possible Wet Area )i S feet feet feet Property Line 2,&"' Drinking Water Well -- Other feet feet 4. Parent Material: :J: ` 1 \ Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s)❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: L-A S 3 inches elevation ' Cnil Aeenee.v.--4 9r n- C;4— Ql u-- I'lir.....-.,I C--- h —t-7 Massachusetts Department of Environmental Protection Bureau of Resource Protection W - U Site Address or Map/Lot Number Program 11 - Soil SuitabilitY Assessment for On-Ste Sewage Disposal Deep Observation Hole A: Deep Hole Number: 2 Soil--- Soil Matrix: — Redoximorphic Features Soil Depth Horizon/ Color-Moist Coarse Fragments Soil Structure Layer (mottles) Texture o Soil (in.) Y (Munsell) (USDA) �O by Volume Consistence Other Depth Color Percent (Moist) Gravel Cobbles 8 Stones Z,Sy S�� ` S= 71S��2S�g Additional Notes Massachusetts Department of Environmental Protection y (v f"5—\n I 1��._" Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number It� Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole A: Z O k o,. 00 sv"N Date Time Weather 1. Deep Observation Hole Logs Deep Hole Number 3 Ground Elevation at Surface of Hole Location (Identify on Plan )_ �� �►✓ ,� (n e vw-Z 2. Land Use: V`-e S Lbw )A__ (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body 1n On Drainage Way n 0"\t Possible Wet Area 7 /Od � feet feet feet Property Line 9_1 - Drinking Water Well qQ­,-e Other Y)o�Q feet feet 4. Parent Material: 'I'"M Unsuitable Materials Present: Yes4--N-o If Yes: Disturbed Soil❑ Fill Mated al'Impervious Layer(s)❑ Weathered/Fractured Rock❑ Bedrock❑ J 5. Groundwater Observed: Yes ❑ No ❑ i If Yes: Depth Weeping from Pit 00 Depth Standing Water in Hole 1 Estimated Depth to High Groundwater: 5-7 -9 S L-i,d inches elevation r1FD C.,.m 14 Cn:1 k;14- Aeenee.v--4 r. rA- C;4- Massachusetts Department of Environmental Protection c_ LI Bureau of Resource Protection — Wastewater Permitting Program -- �1 e1c� �' V Form 11 - Soil Suitabilit Assess Site Address or Map/Lot Number Y Assessment for On Sewage Disposal Deep Observation Hole B: Deep Hole Number; V Soil Soil Matrix:- Red oximorphic Features - Depth Horizon/ Color-Moist Soil Coarse Fragments ---- Layer (mottles) Soil (In.) . (Munsell) —_ i ) (USDA) % by volume Structure Consistence Other Depth Color PG ercent ravel Cobbles (Moist) •�— 8 Stones �J FIUL fi 4 5? 9 ► oiV,5A, sal n d C� Additional Notes Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wastewater Permitting Program Site Address or Map/Lot Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two Boles required at every proposed disposal area) Deep Observation Hole A: 2-1140 1:1 0 o S Date Time Weather 1. Deep Observation Hole Logs Deep Hole Number -# _ Ground Elevation at Surface of Hole - Location (identify on Plan ) Fn!2cr'1+-'t 2. Land Use: Y`eS LXe.-j '�-- (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body C_ Drainage Way V1 01-e Possible Wet AreaOn feet feet feet Property Line '10 Drinking Water Well h t7ti Other feet feet 4. Parent Material: -�-�, �� Unsuitable Materials Present: Yes d�o❑ If Yes: Disturbed Soil❑ Fill Material[Lfilmpervious Layer(s)❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No ❑ If Yes: Depth Weeping from Pit__.(P - Depth Standing Water in Hole Estimated Depth to High Groundwater: 50 C__I_544 Q inches elevation 1 r1CD Cnrm d� Cnil Q..;#,k;Ii4. n ecc.o c.v.e.ni i...(ln C:1.., C.,.....n... n:...,.....,� _ 0...... 7 n0 7 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection — Wastewater Permitting Program Form 11 - Soil Suitability Assessment for On-Si Site Address or Map/Lot Number - - - to Sewage Disposal Deep Observation Hole B: Deep Hole Number.- Soil Soil Matrix Redoximorphic Features Horizon/ Color-Moist Soil Coarse Fragments Soil Soil Depth Layer (mottles) Texture (In ) Y (Munsell) % by Volume Structure Consistence Other — _ (USDA) Depth Color Percent (Moist) Gravel Cobbles J & Stones 0_ L l \ ZtfS S , - Additional Notes Massachusetts Department of Environmental Protection Li (e 12✓t��ty� ��,2,� Bureau of Resource Protection — Wastewater Permitting Program Form 11 - Soil Suitability Assessment for On-Site Sewa a Dis Site Address or Map/Lot Number (.,tom g posal D. Determination of High Groundwater Elevation T4-- \ Pf?_ -�+ 3 1. Method used: ❑ Depth observed standing water in observation hole A. B. inches inches ❑ Depth weeping from side of observation hole A. B. 2 � inches inches --6eto soil redoximorphic features (mottles) A. 1-(S B. L S-- �? So-- A. _.. inches �1 ❑ Groundwater adjustment (USGS methodology) A. B. inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of natura�l) occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes L�No❑ b. If yes, at what depth was it observed? Upper boundary: Lower boundary: inches inches F. Certification f I certify that I have passed the soil evaluator examination"approved by the Department of Environmental Protection and that the above an sis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. gnature of Soil Evaluator I 'Do J v�_S Dat—a T— Typed or Printed Name of Soil Evaluator `Date of Soil RncEvalu for Exam 1 1 / ti L�`Pi 1A' h'11��'R t`„e✓L. Cc�'�,5��.,t'• Name of d'oard of Health Witness Board of Health Note: This form must be submitted to the approving authority with Percolation Test Form 12 ' Massachusetts Department of Environmental Protection Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Use this sheet for field diagrams: J 1, Commonwealth of Massachusetts City/Town of Percolation Test Form 12 Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. 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 the local Board of Health to determine the form they use. Important: When filling out A. Site Information forms the computer,use G o"o R�n:c+' t only the tab key Owner Name c move your (a A, �. '—r8" � cursor- et not Street Address or Lot# —� V use the return i/�^ +n OX R key. l��� `� 0 r I ' Y 1 Ci own ZVI\4e,0—\191�.Stat� Zip Code e (-' GJe2\\\\ Contact Person(if diWent from Owner) Telephone Number t B. Test Results _ L Date ZI1c„�p� i Zc7 Date Time Date Time Observation Hole# �r Depth of Perc r' Start Pre-Soak ' 0�_(Do 1 End Pre-Soak L 0 S 1-3s Time at 12" 0 I 1 " S5 Time at 9" - r 1 Time at 6" Time(9"-6") 3y-vn 1 ✓) Rate(Min./Inch) Z tM► V) I ✓V)1 -1 Test Passed: [ Test Passed: Test Failed: ❑ Test Failed: ❑ Test Performed By: Witnessed By: rn^ 1 Comments: �' Jf 8 t5form12.doc•06/03 Perc Test•Page 1 of 1 �.J !� mac: fq Ck c (0. 3 �e FORM U - LOT RELEASE FORM 0 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ** APPLICANT FILLS OUT THIS SECTION APPLICANT_ b C`p�''�'e �10 titer PHONE LOCATION: Assessors Map Number _ PARCEL SUBDIVISION LOT (S) STREET 1` L-f C -Ti L,4_✓1,xJ ST. NUMBER 7 OFFICIAL USE ONLY tCOERtVATION-ADMINISTRATOR AT S OF TO ENTS: DATE APPROVED V DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED S I INSP OR-HEALTH DATE APPROVED n DATE REJECTED--/ COMMENTS O PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 JM \j,) e- oj ,,tea a �-ei J 1:7 r �lam- �- 9' ice.. -,A a- 1 30 �j��r1 � ��Ef�� - ./• FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and ^-partments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. At55,PLICANT FILLS OUT THIS SECTION T • '`Ji-�itL.ES (/1 . Cl.(/� C � � � X31— S�3/ —Sghc.✓f"z� APPLICANT ,!!qZ /,9 -.r ZZV)�G PHONE 53 LOCATION: Assessors Map Number PARCEL_ SUBDIVISION LOT (S) STREET 7 C�� l) L����� /f L� � ST. NUMBERV� lOFFICIAL USE ONLY i REC MMENDATIONS OF TOWN AGENTS: CONS R ATION ADMINISTRA OR DATE APPROVED DATE REJECTED I I COMMENTS i i I TOWN PLANNER DATE APPROVED DATE REJECTED i COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPT INSP OR-HEALT DATE APPROVED y IDATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE i COMMONWEALTH OF MASSACI�u—S ETTS lugEXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: f. �C.i�h3 OF NORTH ANUG, ' .i/ NQ 1 BOARD OF HEALTH Owner's Name: Owner's Address: 1;.1 ju . Date of Inspection: S:, Name of Inspector: (please print) f 4cc J Company Name: Mailing Address: _ Telephone Number: a (pp CERTIFICATION STATEMENT I certify that 1 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 Conditionallv Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature Date: The system inspector shall submit a copy of this inspection reportto 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. Notes d Comments I CJ "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. Title 5 Incnertinn Fnrrn 4/1lq/7AAA ____ Page 2 of 11 J ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: § 1ct 7— o, Owner:-,4j-dl t-14- Date of Inspection: S^/,�--A Li ___ Inspection Summary: Cbeck 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 1�.3 3 or in 310 CMR 15.304 exist. Anv failure criteria not evaluated are indicated below. Comments:Jo JJ 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. Answer yes,no or not determined(Y,N,ND)in the 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 tan}; is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken,senled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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): r broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION(continued) Property Address: i et ^/}vYtO Owner / •� Date of Inspection: C. Further Valuation is Required by the Board of Health: Conditio exist which require further evaluation by the Board o ealth in order to determine if the system is failing to protect ublic health;safeR or thaenvitonment. I. Svstem will pas unless Board of Health determines in ccordance with 310 CMR 15.303(1)(b) that the system isnot func ' ning in a manner which will pro ct public health,safety and the environment: _ Cesspool orprivy i within 50 feet of a surface atcr — Cesspool or privy is . in 50 feet of a borde g vegetated wetland or a salt marsh 2. System will fail unless the Board of H th (and Public Water Supplier,if any)determines that the system is functioning in a manner that p/ a is the public health,safety-and environment: -- The system has a septic tank and toil abso tion system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to 7urface wat supply. The system has a septic tank d SAS and the S is within a Zone I of a public water supply. _ The system has a septic and SAS and the SAS is . ithin 50 feet of a private water supply well. _ The system has a septi tank and SAS and the SAS is less n 100 feet but 50 feet or more from a private.water supply well - Method.used to determine distance "This system passes ' the well water analysis, performed at a DEP cc ified laboratory, for coliform bacteria and volatile rganic compounds indicates that the well is free fro pollution from that facility and the presence of a onia nitrogen and nitrate nitrogen is equal to or less th 5 ppm, provided that no other failure criteria triggered. A copy of the analysis must be attached to this 3. Oth 1 , � Page 4 of I] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:t4(o r Owner: Date of inspection: LL D. System Failure Criteria applicable to all systems: You must indicate `Yes"or"no"to each of the following for all inspections: Yes IJo Backup of sewage into facility or system component due to overloaded or clogsed 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 V: day flow _Y,.,_ 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 hi ' water elevation. Any portion of cesspool or privy is within 100 feet of a surfagrocedwater 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. ('Phis system passes it the well water analysis, performed ata DEP certified laboratory,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,provided that no other failure criteria are triggered. A copy of the analvsis must be attached to this forma ,AU (Yes/No)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 facilitywith a design flow of 10.000 gpd to 15,000 gpd. You must indicate either"ves"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 Il 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. Page 5 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART B CHECKLIST Property Address. Owner: Date of Inspection: —�S'�'�j Check if the following have been done. You must indicate `wes"or`oto"as to each of the followins: xis 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 ? Q _ 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: 7Existing no 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) [3 10 CMR 15.302(3)(b)) 5 Page 6 of I I J i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS_A,L SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: a � Owner: Date of Inspection: �FL W CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 4 of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): /V Is laundry on a separate sewage system(yds or no):2�j [if yes separate inspection required] Laundry system inspected(yes)or no)::L Seasonal use: (yes or no):Ll.l Water meter readings, if available(last 3 years usage(gpd)): Sump pump(yes or no): � Last date of occupancy.-.'fir t•�'�_ C O M M E R CIALIND U STRIA L Type of establishment: Design flow(based on 310 CMR 15.303):— -and Basis of design flow(seats/persons/sgft.etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: - Last date of occupancy/use: OTHER (describe): _ Pumping Records GENERAL INFORMATION Source of information: Was system.pumped art of a inspectio (ves or If yes, volume pumped:_—gallons— How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system _ Single cesspool Overflow cesspool Privy /a 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) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all componen date it}stallcd(if known)apda source of information: Were sewage odors detected when arriving at the site(yes or no):,&j Page 7 of 1 l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Address: CA �Voellj Cwner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: N-13tenals of construction:_cast iron _40 PVC_other(explain): D;st.ance from private water supply well or suction line: Cc rrtments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: X(locate on site plan) Dc:)th below grade: Matenal of construction: _concrete _metal _fiberglass_polyethylene --other(explain) if Link is metal list age:— Is age confirmed by a Certificate of Compliance (yes or no): _(anach a copy of cer.ificate) Dimensions: Slu.ige depth: Distance from top of sl�dge to bottom of outlet tee or baffle: X26- t Scum thickness: 'e � Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle: 17 How were dimensions determined:'% Comments (on pumping recommendatio s, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related o outlet invert, evi once of leakage-,,etc.): GREASE TRAP: _(locate on site plan) Dcpt-i below grade: _ Material of construction: _concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scurr, thickness: Distance from top of scum to top of outlet tee or baffle: Dista,-)cc from bottom of scum to bottom of outlet tee or baffle: Date :)f last pumping: Comr,�ents (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page S of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -7wt,tj Owner: , Date of Inspection: 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./day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:,_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: d Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of eakage into or put of b x, etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of I 1 f r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: ),,1ro-41 , Date of Inspection: c%�S=6 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not Ipcated explain why: Type leaching pits. number._ leaching chambers,number. leaching galleries, number. � leaching trenches, number, length: ::JJpyl/Z )S, e/ leaching fields,number, dimensions: overflow cesspool, number: innovativeialtemative system Tvpe!name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding damp soil, condition of.vegetation, etc.): AJ6 �n2 CESSPOOLS: (cesspool must be pumped as part of inspeetion)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum layer- Dimensions ayerDimensions of cesspool: Materials of construction: Indication of eroundwater inflow(yes or no): 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.): Page 10 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ti Owner: i Date of Inspection: _/,('-G� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. e6 L � y 1 Ul! A r Page I I of I I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Address: ,d ft f veas-,) Owner: k/ /ICA., Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high around water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting properryiobservation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators. installers-(attach documentation) Accessed USGS database-explain: Y u must describe h wyou es blisl�ed the high ground water elevation,� 4(0 ry v C� t i ke_V<_j 4-0/ 2-t j_T te-es -zi b Sv 1 c 0v-t1v. LIA 3�K Ai 6 rL Jw A-4�C t h !up es J kj- des � RIC --�ot 12 Rawleigh Tavern Ed. Off Farnum St„ Osgood Realty Trust APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Lot 12 Rawleigh Tavern rd. . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 1000 in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 200 lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia. ) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/41' (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE 27- - � Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of n pecting Officer Percolation Test 5 min Soil: Clay Garbage Grinder BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. so — 1. NAMEDAT_-CiA.d 2. ADDRESSal qLOT N0. i� TEL. 3. NO. OF BEDROOMS DEN YES NO K, 4. GARBAGE GRINDER . YES N0�_ 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL g. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. O O BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS SEWAGE DISPOSAL NAME OF APPLICANT LOCATION Addre of lot no, BUILDING: Dwelling X Other SYSTEM: New X- Repair GENERAL DESCRIPTION OF LAND SUBSOIL: Clay__ Aavel Sand PERCOLATION TEST minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK gallon capacity. LEACH FIELD `Z lineal feet of drain pipe, dd, illiam J. r scoll, Engine. Board of Hea t