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Miscellaneous - 46 WHITE BIRCH LANE 4/30/2018 (2)
--1 m C7 o = o � z O m' i • 1 MAP # t LOT PARCEL # STREET CONSTRUCTLON ARPROV., HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE b Z �� APP. BY DESIGNER: PLAN DATE. _7 Z 7IgL ' CONDITIONS WATER SUPPLY: TOWN WELL WELL PER WELL TESTS: CHEMICAL CtERIA I BACTERIA II COMMENTS: DAZE APPRUVED DA I E (IPPRUVED DAZE APPROVED FORM U APPROVAL: APPROVAL TU ISSUE Y NO DATE ISSUED ��� A, By _ /1 _.... ..................... CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL YE NO SEPTIC SYSTEM CONSTRUCTION APPROVAL ES NO OTHER -S NU ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO DATE: %��.1_ . BY . !r 9 ' ! 1 LOT MAP # PARCEL # CONSTRUCT LON__APPROVAL HAS PLAN REVIEW FEE BEEN PAID? PLAN APPROVAL: DATE ll APP. BY__ ��____.___ DESIGNER. ,ST� �J PLAN DA FE;_ 74121 4 - CONDITIONS G�o�uFiervliNC �D��i° f�Oc S. cub o 5y,r�til �.e1bR- - o Chdi5r2cJG7-404) --- WATER S PLY: -_TOWN WELL WELLPERMIT__ _ DRILLER._..._ __.__ __._....__._._ ___..._...._._ _._._..:._ ._...._.......... WELL TESTS: CHEMICAL UAIE A{'F�fZUVED,_.___.__.......... __. BAC- IA I DA f E (IPPRUVEU BACTERIA I DATE COMMENTS: FORM U APPROVAL': APPROVAL TO I5S`U�L-- YES `NU DATE ISSUED BY -_._.__ ..—_.._.__..._.._..__..._ .._._— CONDITIONS: FINAL APPROVAL:. YES NO ALL PERMITS PAID YES NU WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL YES No OTHER YES NU ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO DATE: ..............._..._ ...BY:.._.. r � } 5EPTIG_5.XFLTEM_.NSI841,8T.QN :IS 'THE • INSTALLER LICENSED? YES NO r t '• ^.. . � 'sem •! . . Jt .-'.TYPE. CONSTRUCTION: ? -CONSTRUCT- NEW REPAIR'' - . - .. ..NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO t F CONDITIONS OF:. APPROVAL YES NO ' FROM .FORM U) , J` �� a i ; 'fes t •� .•1• f , .. r:. +.. ... �,ISSUANCE OF DWC PERMIT ._ YES NO ,DWC PERMIT N0. 1 INSTALLER: • .t BEGIN INSPECTION YES N0: ' - EXCAVATION , INSPECTION: :NEEDED: _ PASSED ' `' y . .BY ', :';CONSTRUCTION INSPECTIONS .: ;- .::; NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL -7O BACKFILL: DATE: BY " .FINAL•GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE: BY ... .. •� • ' •1 . • __ ! 1• ` `/ -. 11'3••'/ • - - � � NORTq Town of North Andover �SS�cMusO� HEALTH DEPARTMENT CHECK #: r DATE: ri LOCA H/O t CONT 7140 Type of Permit or License: (Check box) ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type: ❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑ Tras4lSolid Waste Hauler ❑ Well Construction SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector Title 5 Report ❑ Other: (Indicate). MAM Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer =cv�_ 3�f1- Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q ienxn Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner's Name North Andover City/Town MA 01886 State Zip Code RECEIVE(1; JUL 0 g Z019 A HEALTH D AWMW June 25,2015 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. A. General Information Inspector: John DiVincenzo Name of Inspector Stewarts Septic Serive Company Name 58 South Kimball street Company Address Bradford MA City/Town State 978-372-7471 S113386 Telephone Number License Number B. Certification 01835 Zip Code 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 ❑ Ne/sjurthgr Evo ation W the Local Approving Authority Ihce ector's Signature Date system inspector shall sub it a py of this inspection report to the Approving Authority (Board of Health or DEP) within 30 da s 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner's Name North Andover MA 01886 June 25,2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01886 State Zip Code June 25,2015 Date of Inspection ❑ 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 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover MA 01886 June 25,2015 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner's Name North Andover City/Town B. Certification (cont.) Yes No MA 01886 June 25,2015 State Zip Code Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or ❑ ❑ obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover MA 01886 June 25,2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): A 1) Number of bedrooms (actual): anr% DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 i Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'GSM 46 White Birch lane Property Address Gallons per day (gpd) Betty Pauline Yes ❑ No Yes ❑ No Yes ❑ No Owner Owner's Name information is required for every North Andover MA 01886 June 25,2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No Occupied Date t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Gallons per day (gpd) ❑ ❑ ❑ Yes ❑ No Yes ❑ No Yes ❑ No t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 46 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State 01886 June 25,2015 Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Stewarts 1500 gallons Site quape on truck Inspect tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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): l5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 0y, 46 White Birch lane D. System Information (cont.) MA 01886 June 25,2015 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 21 vears Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 22"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.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal Rl feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Property Address Betty Pauline Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) MA 01886 June 25,2015 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 21 vears Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 22"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.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal Rl feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No 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 w„ 46 White Birch lane D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 29" 1" 5" 14" June 25,2015 Date of Inspection How were dimensions determined? Tape measure & sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No leakage liquid level good both tees in good condition. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Property Address Betty Pauline Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 29" 1" 5" 14" June 25,2015 Date of Inspection How were dimensions determined? Tape measure & sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No leakage liquid level good both tees in good condition. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover MA 01886 June 25 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner's Name North Andover MA 01886 June 25,2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Equal dist little solids carryover pumped and cleaned box no 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover page. City/Town MA 01886 June 25,2015 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1-20X59 number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no hydraulic failure no ponding no damp soils. 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 White Birch lane Property Address Betty Pauline Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) nnn 01886 June 25,2015 Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 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 wM 46 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover MA 01886 page. City/Town State Zip Code June 25,2015 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 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 46 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover MA 01886 June 25 2015 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 24" 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: May 10,1994 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Pulled Files ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Taken from design plans water table at elevation 156.0 bottom of bed at elevation 160.0 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 w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 46 White Birch lane Property Address Betty Pauline Owner Owner's Name information is required for every North Andover MA 01886 June 25 2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 W 2 Q J 3 LOT 1 8, LOT 2 AREA = 21,780 S.F. 22.9-11-1 LOT 3 � 228.54' 4 ELEVA TIONS 14' D -BOX 40 .' 51' EXISTINGr 1 S00 GALLON A FOUNDATION SEPTIC rwx (TDP END. 26 ' I = 16442) 38' 162.07 162.12 INV. OF PIPE AT SEPTIC TANK OUTLET 161.82 o INV. OF PIPE AT D -BOX INLET O / a/ pE LOT 2 AREA = 21,780 S.F. 22.9-11-1 LOT 3 � ELEVA TIONS DESIGN AS -BUILT �o INV. OF PIPE OUT OF HOUSE 162.57 162.5 INV. OF PIPE AT SEPTIC TANK INLET 162.07 162.12 INV. OF PIPE AT SEPTIC TANK OUTLET 161.82 161.91 INV. OF PIPE AT D -BOX INLET 161.50 161.80 INV. OF PIPE AT D -BOX OUTLET 161.33 161.62 INV. AT END OF DISTRIBUTION PIPE 1 161.00 161.10 I HEREBY CERTIFY THAT I HAYI INV. AT END OF DISTRIBUTION PIPE 2 161.00 161.12 OF THIS DISPOSAL SYSTEM AM FINAL GRADING HAS BEEN IN -4 INV. AT END OF DISTRIBUTION PIPE 3 161.00 161.15 INTENT AND THAT THE MATERIA SPECIFICATIONS AND 310 CMR INV. AT END .OF DISTRIBUTION PIPE 4 161.00 161.14 �!6.9, Alz L N 4 VENT 54' 40' �^ 4 o`"J $. SPECTER THE CONSTRUCTION IAT THE CONSTRUCTION AND IRDANCE WITH . THE DESIGNER'S USED CONFORM TO THE PLAN 70. NOTE: THIS PLAN IS NOT A WARRANTY OF THE SYSTEM BUT A VERIFICATION OF THE LOCATIONS OF THE EXISTING STRUCTURES. AS BUILT PLAN .y6 OF SUBSURFACE DISPOSAL SYSTEM AT L 0 T 2 WHITE BIRCH Il _ IN NORTH ANDOVER, MASS. PREPARED FOR: SCOTT CONSTRUCTION CO. SCALE: 1" = 20' DATE: OCT. 26, 1995 CHRISTIANSEN SERGI PRO FESS10,"VEN SEERS L4ND SUR160 SUMMER ST HAVERHILI,MA. 01830 TEL 508-373-0310 © 1995 BY CHW57MNSEN 3 SEM INC. DRAWING NO. 93067019 v v v v v .► v N N I, cn V V V V Y Y Y W y V y O Z WHITE BIRCH LANE .00'001 C) Allo Z a s y'a ZaZ C oa y Ll LoRt y o y �to �a y ,LL'06 00 v m t o �o -rt o m a m m �' N m O L EJ C cc O V � C p MZ =C m CDC 'b ^xn 0 O cn ►id y (�('� • y O ti. c N C Q CD CD CD Z ynaC v m ..c b 4� y C � CD Im o c y o --1c Ty � C7 O D n Z y CD r o = _ y O cm) CD d y . CDCL O r cr r.} m H CD C7 O CD O CD m W O CD 3 y. < Qv y oCO CD y z — S CA v o m M C 'O O Z O x•�b3 ^" CA C? CD 0 z D a®�: c CD v m t o �o -rt o m a m m �' N m O L EJ C cc O V � C p MZ =C m CDC 'b ^xn 0 O cn ►id y (�('� • y O ti. c N C Q CD CD CD CD ynaC 3. m ..c b 4� y ..►_ .Ortm .-� d O CD Im o c y o --1c C3)r a o-0 O yA CD CS OC CD CD CA d y . C G d. Q C 0o a m H CD su CA � O O O : CD 0N y .j � O m M C CD x•�b3 ^" CA C? G7 = ?� a®�: bo :rc o cn �C kt000l CIS n m T m CIO x m Cn Cf D w rD do�� a � oG c4D-0.r r Cn o p xo a i z b 4� f" '9 m r v z 0 11 y 0 f NORtp o � A i ssAcmuSE� Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 8 , 9-G!!- 0 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. Site Location_ (ADi Reference Plans and Specs Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIRMAN, BOARD OF HE Site System Permit No. 23-3 H OR7M of {O- 9 ,SSACHUSEt Applicant Town of North Andover, Massachusetts BOARD OF HEALTH OST— 4 19 DISPOSAL WORKS CONSTRUCTION PERMIT Form No. 3 NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 73-3 Fee 4j CHAIRMAN, BOARD OF HEALTH D.W.C. No. WHITE BIRCH LANE 100.0' BUFFER AREA o 35.8' T.F. 164.42' N N LOT 2 N AREA=21780 S.F.I :– 90.8' FOUNDATION LOCATION PLAN CLIENT. JPD DEVELOPMENT THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER,MA. SCALE: 1" = 40' DATE: AUG.29, 1995 CHRIS TIA NSEN & SERGI PR LAND SURVEYORSEERS 160 SUMMER ST. HAVERHILL.MA. 01830 TEL 508-373-0310 © 1995 BY CHRISTIANSEN & SERGI INC. 8.3' — — TOW BOARD OF 'EA4ll - SEP 21 10 I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CER77F1CATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS, WETLANDS,EASEMENTS, ORDERS OF CONDITIONS,£TC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE.EXCEPT W?H THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN A SERGI INC. AND ANY UNAUTHORIZED USE 1S PROHIBUED.CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MA170N CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. COMMUNITY NO.: 250098 0005C DATE, •612193 OF Mgs�gc MI EL J. SER H N 33 1 0� a .T F DRAWING No. 93067016 FORM U - LOT RELEASE FORM 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 local or state law, regulations or requirements. k. ****************Applicant fills out this section***************** APPLICANT: SC C) -57y_ ( ' oyx J r C Phone _77 V - O 0-7 Y LOCATION: Assessor's Map Number Subdivision Street Parcel Lots) St. Number ************************Official Use Only************************ jCMMENDA ONS OF TOWN AGENTS: �kDate Approved Conservation Administrator Date Rejected Comments Town Planner Comments Food InspecorHealth ;7z-,6 Septic Inspector -Health Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Commentsp '_ /Z/DX. '-O T-1010 Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 July 26, 1995 Ms. Sandra Starr North Andover Board of Health 120 Main Street North Andover, MA 01845 Re: Lot 2, White Birch II Dear Ms. Starr: In response to your letter of disapproval dated July 17, 1995, please find the enclosed revised plans for your review. A list of our responses to your reasons for disapproval are as follows: 1) No benchmark within 50 feet to 75 feet of the system. An appropriate benchmark has been added to the plan. 2) Please check breakout; it should be 161.66 to the top of the stone. The breakout grading is correct as shown. The 20 foot separation indicated between the edge of the leaching facility and the 160 foot contour has been calculated as follows: —The horizontal breakout distance to the 161.66 elevation is 15'. —The horizontal distance between the 161.66 elevation and the 160.00 elevation along a 3:1 slope is (161.66 - 160.00) x 3, or 5.0'. —15' + 5' = 20' between the edge of the leaching facility and the 160 foot contour. 3) Need an additional deep test hole in the reserve area. At least 11 test pits have been dug within 150' of the proposed reserve area. The results of these tests clearly show consistency within the the soils in the area. 6 of these test pits (Test Pits 94-10 through 94-15) were performed on lots 1 and 2 on the same day during very wet conditions. The groundwater depths recorded in these tests ranged from 24" to 48". None of these test pits had more than one "C" horizon. No ledge or refusal was encountered in any of the test pits. The leaching facility on lot 2 has been designed with a groundwater depth of 24". The percolation test within the reserve area was performed at a depth of 58". All of this information shows clearly that there is a sufficient receiving layer in the reserve area. (It should also be noted that there will be at least 5.5' of sand fill under the leaching facility due to the high groundwater and the necessary excavation of the topsoil and subsoil.) If you still feel it is necessary to perform another test pit, please schedule it at your earliest convenience. %- 14 Lot 2 White Birch (Page 2) 4) Leaching area not 35 feet from the foundation drain. The proposed leaching facility is clearly shown (by scale) to be 36 feet from the foundation drain. This dimension was not shown on the plan because the reserve area, at a distance of 35', was closer. The lesser dimension of 35' was presented on the plan. I have added the 36' dimension to the enclosed revised plan. I trust that this information sufficiently addresses the issues raised in your letter of disapproval. Please call me if you have any questions. Ve Truly You s Daniel J. O'Connell Encl. c.c. Dan Betty BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 July 17, 1995 Christian & Sergi 160 Summer Street Haverhill, MA 01830 Re: Lot #2 White Birch Lane Dear Phil: TEL. 682-6483 Ext23 This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) No benchmark within 50 feet to 75 feet of the system. 2) Please check breakout; it should be 161.66 to the top of the stone. 3) Need additional deep test hole in reserve area. 4) Leaching area not 35 feet from foundation drain. If you have any questions, please do not hesitate to call the Board of Health Office at 688-9540. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp DESIGN REVIEW SHEET LOT 2 WHITE BIRCH LANE PERMIT # 733 REC'VD 6/8/95 APPLICANT: DAN BETTY ENG: CHRISTIANSEN 160 SUMMER ST., HAVERHILL PLAN DATE: 4/24/95 DISAPPROVED NO BENCHMARK WITHIN 50' TO 75' OF SYSTEM PLEASE CHECK BREAKOUT; SHOULD BE 161.66 TO TOP OF STONE. p �3. NEED ADDITIONAL DEEP TEST HOLE IN RESERVE AREA. -- / 9-'3/ cd 14'5" - [)r4. LEACHING AREA NOT 35 FEET FROM FOUNDATION DRAIN. No ................ ........ •vwN —�- F THE COMMONWEALTH OF MASStL =` BOARD OF. HE1995 .._._Town/ OF t NAppliration for DispasalWorks'rt Application is hereby made for a Permit to Construct (YQ or Repair ( ) an Individual Sewage Disposal System at: ...............4A.Ke ..................... _.._.._... ........ ............ ...._.......... Location - Address or Lot No. QTT.. ?Nsl uc►tvl�...t.) ... 1.N.et.......... .... .... 12M..K� Owner Address .................................................................................................................................................................................................... Installer Address Type of Building Size Lot ...... Z.1.).7E0... Sq. feet Dwelling — No. of Bedrooms........................................Expansion Attic ( ) Garbage Grinder ( ) Other —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ....�................................................................................................................................................ Design Flow ............. z..._...._....64J`....... gallons per person per day. Total daily flow ............. (P.10 ................... lf Septic Tank —Liquid* capacityl-FQOgallons Length..10.-.6... Width..6.'MB... Diameter......-....... Depth.S .... �.. Disposal ... Width .... 2.t7......... Total Length ....... 5........ Total leaching area ...1/.8.d....sq. ft: Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................sq. ft. Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by ... C.HI.tI.QAtq-41.1..S-6-1+..1-A/C.1..... Date...-5).%..f.._._7j Test Pit No. l .... 12 ....... minutes per inch Depth of Test Pit...... !!..... Depth to ground water...... ......... Test Pit No. 2 .... 12. ......minutes per inch Depth of Test Pit ....... 04.1r... Depth to ground water ...... 24.......... Descriptionof Soil.......FJ#: ... ............................................................................................................... ........................................................................................................................................................................................................ Nature of Repairs or Alterations — Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal .System in accordance with the provisions of T I T LE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... .......................... Date ApplicationApproved By................................................................................................_........................................ Date Application Disapproved for the following reasons: ................................................................................................................ ...................................................................................................................................................................................................----- Date PermitNo .................................................... Issued ...........-----------.........---.............. Date .— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... OF ........ . ..........I ........................... Tatif iratr of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................................................................................................................................................................................ Installer at..................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ...................................."... dated ................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector....................----............................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF. No......................... FzE ........................ �i��luottl orko �ono�rnr#ion �rrmif Permission is hereby granted ................................................ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.................................................................... .......................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No ..................... Dated.......................................... ......................................................................................................._ - Board of Health DATE............................................................. No......................... Full ............. _.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN Appliratiilin for K1i,oFI111Ml wvrhii T11111itrartilih puniit Application is hereby made for a Pernllt to Construct ( x) or Repair ( ) an Individual Sowage Disposal System at: CHERISE CIRCLE � ..................Location • AJJrc.s................................. Lot.No.............................. ............ ...........�.OTT...�.Q.NS);RUG� Z.QtI...��i�......................... 1.�...RQG;ERS.. RD..RUE.R.U. LL ..I �.. Owner Address ............................................................................. .............. .............................. ...................................... InstallerAddress Type of Building Size Lot... ?��,,.7 ....Sq. feet Dwelling —No. of Bedrooms ............. 4............................. Expansion Attic ( ) Garbage Grinder (• ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures................................................................................................................:..................................... Design Flow.............8.2.:.5.................... gallons per person per day. day. Total daily flow .............. Septic Tank — I.iquid'ca acit .UQ.'all ns Len thI....'..�Widt .§..—A'.. Diameter ................ Disposal Trench — No.3...... Width ..... 2.......... Tota.l Lengt ..6--�;....... Total leaching area.......D.,..e..p..t.h....y5..g..t.a ..s'lq.2it" Seepage .. Seepage Pit No ..................... Diameter.................... Depth below inlet................... Total leaching area........... ..sq. ft. Other Distribution box ( x ) Dosing tank ( ) 1OZ4,,_ ,.7/,, �f/ / Percolation Test Results Performed by..... C H R I S T I A N,$ E I� & S E R G I N CDate...- ° .�,`'p/`� .......... Test Pit No. l ...............minutes per inch Depth of Test Pit......:�4�...... Depth to round water..... u7. � Test Pit No. 2......%.a.... �� P g........... minutes per inch Depth of Test Pit......`f....... Depth to ground water ...... X ... Description of Soil............................................................................. .................................................................................................... ..................................:��.�..... y..,...�� ::....:::1y..�... c� ...:1.. .......... Nature of Repairs or Alterations Answer when applicable......................`......`�.......,..�.......„•,,,,••..•.....•.....•............... ................................................................................................................................... .......................................... Agreement : ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI': ll-, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health, Signed...................................................................................... ........7' te Application Approved By.......................................................................................................................... .........�.......... Application Disapproved for the following reasons: ............................................................................................ Dnlc.................... .............................................................................................................................................................. Date PermitNo ......................................................... Issued............... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................... OF Tatif iratr of T uipiialirr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................................................................................................. .............................................................................................. Installer at................ ......................................................................... .....................:.... ............................................................................. has been installetcl in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Constr-action Permit No ......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.................................................................. OF $ . ...........I........ ............................... ................ Fsu........................ Dtopgal Ivor Vaunt Permissionis hereby granted..................................................::.......................................................................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System. . atNo............................:......................:.........................................._:...:..................:....................................................................... Street as shown on the application for Disposal Works Construction Permit No.... ... .............. Dat'd .......................................... ......................................................................................................... DATE................................................................................ Board of Health FORM 1255 A. M. SULKIN, BOSTON No......................... Fua..........._.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......TOWN.........................OF........... ...N9RT ....AND.9Y. R..................:....... . Appliralinll for D.5Vla,5;tl juurjW T111I. trttrfiih Frruti# Application is hereby made for u Hermit to Construct ( x ) or Repair ( )tut Individual Sewage Disposal System at ................. CHER.I.SE CI........................... ..................... �. Location • Address .......................Lot.No................I......................... 12 ROG'ERS RD or �.Q.T.T...C.Q.N S )rpt U Cw I.Q l`1... ��i �....................................................................R A �.� R.N.T L L.t... r:! �.................. Owner Address ..................................... I ......... Tnstal. lcr ............. I.................I........................... Type of Building ...................................Addre`9...... 9 .7 Size Lot.... ,► ....Sq. feet Dwelling —No. of Bedrooms ............. 4............................. Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ............................ gallons per person per day. Total daily flow.............�.Q .................... gallons. Design Flow.............$.2.:.5.........5...0... �? Septic Tank Liquid ca acity. Q.....galIons Length !.Q t?,. Width.?. �.',$,��, Diameter.... ' — ...... ........ Depth. �....-.�.... Disposal Trench No .... ..... ...... Width................... Tota) tg'` .6o ;. ..re .. —' Leng ...... Total leaching area....,/./..3.V sq. ft. Seepage Pit No ..................... Diameter.................... Depth below inlet................... Total leaching area........ sq. ft. Other Distribution box ( X ) Dosing tank Percolation Test Results Performed by.....CH.RISTIAN N & �....,,,,, ate..../" $ ............ ERGS jNCD 7iP....... minutes per inch Depth of Test Pit...... !/...... Depth to round water.. ��4` Test Pit No. 1.......�s�... �� ' Test Pit No. 2 ...... %.a�.... minutes per inch Depth of Test Pit...... `?��..... Depth g ,, ��,..... to ground water. ..��. Description of Soil...........................................................:............................................................................................................ ........................................ ....................1............................................................................ .....................................y�'/.c...... ri ..,...$ '�i ........ 1. ........17...... r.............................................. ............................................... Nature of Repairs or Alterations — Answer when applicable ................. ..................... ................... ................................... ..................... .........................................................................I..................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LZ 5 of the State Sanitary Code — The undersigned farther agrees not to place the system in operation until a Certificate of Compliance psis been issued by the board of health. Signed...................................................................................... zS Application Approved B Date y.................................................................................................. .................. n Application Disapproved for the following reasons: ................................................................................... ........................................................................................................................... Permit No ..................... Date .................................... Issued_............... ................................. Date THE COMMONWEALTH OF MASSACHUSETTD BOARD OF HEALTH .................................. I....... OF Tnvfirati' laf C9lampliatirr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..........................................................................................•in;ioiier............................................................,......................... at.................... .. .......................................................................................::................. ....... .................. ............................................ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ......................................... dated.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................. ... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No...........................................•.•.•....Or..................,..........................,................. Fun ........................ Bilivagal rft C nitz #t• r#iun i�eruttf Permission is hereby granted .................................................. ........................ .... ....................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System, atNo ............................ :................................. ........ .................... ....................................................................... I............................ Street as shown on the application for Disposal Works Construction Permit No ..................... Datq'd ........................................... ......................................................................................................... DATE...Board of Health .............................................................. FORM 1255 A. M. SULKIN, 60STON Town of North Andover, Massachusetts Form No. 2 f NORTh BOARD OF HEALTH /J O't•`•e '•,h0 -19 DESIGN APPROVAL FOR ss,C"°SEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant_y / M OP -1 /nO V / Test No. Site Location OT Reference Plans and Specs.— ENGINEER DESIGN DATE i. Permission is granted for an individual soil absorption sewage disposal system to be installed r• in accordance with regulations of Board of Health. � �iCGL�/' CHAIRMAN, BOARD OF HEALTH 9. 2• 7: Fee Site System Permit No. di Z, 4