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Home My WebLink AboutMiscellaneous - 47 WILLOW RIDGE ROAD 4/30/2018 (2)v Pi a L/ 7 ��/ t ' L [ 102 'P� (- J7 L Commonwealth of Massachusetts Town of North Andover System Pumping Record System Owner & Address: Lisa Lawton 47 Willow Ridge Road North Andover, Ma 01845 Date of Pumping: October 03, 2012 Type of System: Septic tank Location of System: Rear yard Gallons Pumped: 1000 gallons System Pumped By: John Zanni Pumping Co. LLC 5 Hallberg Park North Reading, Ma 01864 License #: BHP -2012-0343 Contents Transferred to: Greater Lawrence Sanitary District - --- - - _-.... _.... ... _ Date: October 03,2012 RECEIVED CU'IE.2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT ---- Pumping Technician: PK This is proprietary and confidential information that may be used only by the Board of Health for regulatory purposes s ` 40U6 Town of North Andover HEALTH DEPARTMENT SACMUSt CHECK #: _ �DATE: r/Z�� ' LOCATION: H/O NAME: CONTRACTOR NAME:�1 (q Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors ,.• $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic -Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑�Titlow!5 teosInstallers (DWI) $ spector $ Title 5 Report $ jd• d ❑ Other: (Indicate) $ A i Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer wo 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. V�—Ilbjl retwn t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary, RECEIk/ D OCT - 9 2009 �K its4--- TOWN OF NURTl-1 AtaDOVER 47 Willow Ridge Rd HEALTH DEPARTMENT Property Address Diane Penny��- Owner's Name North Andover MA 01854 9/29/09 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. A. General Information 1. Inspector: Chad Jablonski Name of Inspector Jablonski & Sons Inc. Company Name 167 Willow Ave. Company Address Haverhill MA 01835 City/Town State Zip Code 978-360-9358 4574 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalu the Local Approving Authority /0 tl2 / 0 1 Inspector's Signature / / Date The system in ecto /shall submit a copy of this inspection report to the Approving Authority (Board of Health or EP ithin 30 days of completing this inspection. If the system is a shared system or has a design 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. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Willow Ridge Rd Property Address Diane Penny Owner's Name North Andover City/Town B. Certification (cont.) MA 01854 State Zip Code 9/29/09 Date of Inspection 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: SAS and all components in good workinq order. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 LW Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Willow Ridge Rd Property Address Diane Penny Owner's Name North Andover City/Town B. Certification (cont.) MA 01854 9/29/09 State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 'h day flow t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments nM 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El® 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. El® 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. E]® 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is North Andover required for every page. City/Town C. Checklist MA 01854 9/29/09 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 400 gpd t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? 1.1 Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? 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 Attaehed P9,IV,9-rC-7 WE:L( ❑ Yes ® No Occupied Date t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Gallons per day (gpd) ❑ ❑ ❑ Yes ❑ No Yes ❑ No Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Date Source of information: N. Andover BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: na gallons How was quantity pumped determined? na Reason for pumping: na 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 3 Approximate age of all components, date installed (if known) and source of information: .yrs- Certificate of Compliance Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 17"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: na feet Comments (on condition of joints, venting, evidence of leakage, etc.): Watertight at foundation Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 10" feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: na years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 8'x 5'x 5' Sludge depth: 3" ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection t5ins - 09108 D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measuring tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank structurally sound, components in good working order. Pumping recommended 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 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 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA page. City/Town State D. System Information (cont.) 01854 9/29/09 Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box level and distributing evenly. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CG�M 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1- 25'x 45' ❑ 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 sign of hydraulic failure or ponding Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction indication of groundwater inflow ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M MA 01854 9/29/09 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 47 Willow Ridg Property Address Diane Penny Owner Owner's Name information is required for every North Andover M MA 01854 9/29/09 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 C/jIQ,L_0 k_� G� t t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 —G�bt l� l� C/jIQ,L_0 k_� G� t t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is North Andover MA 01854 9/29/09 required for every page. Cityfrown 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: > 5' feet Please indicate all methods used to determine the high ground water elevation: -/ 01 0 Obtained from system design plans on record If checked, date of design plan reviewed 7/30/1976 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Perc test performed by Joseph Barbagallo 7/20/1976 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 47 Willow Ridge Rd Property Address Diane Penny Owner Owner's Name information is required for every North Andover MA 01854 9/29/09 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 `Commonwealth of Massachusetts AY-City/Townof NORTH ANDOVER MASSACHUSET Sy.Stem' Pumping Record w- Form 4 DEP has provided this form for use by local Boards of Health. The System Pum in Record mu; be submitted to the local Board of Health or other approvin Ara z.:E irC� Lid A. Facility Information Important: DEC 6 2006 When filling out 1. System Location: forms on the , computer, use O NOF ER H D ANDO T only the tab key Address J1-- " — ---.. . to move your cursor- et not City/Town Stat--�8!? —.�_. use the return -------• key, Zip Code 1, 2. System Owner. Name Address (if different from location) City/Town — --'--- State ---- Zip Code p�er 3i0�_ ' Telephone Number ----"` Pumping Record - 1. Date.of Pumping Date V 2. Quantity Pumped: � _,.--- Gallons Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ other (describe): 4. Effluent Tee Filter present? ❑ Yes2'Ko _ If yes, was it cleaned? ❑Yes o 5. Condition of System: 6. SyAem Pumped By: _ name - Vehicle License Number 41 Company 7..: Location where contents were disposed J Si score or Hsu �/ `_, _._.__ Date_.. http://www.mass.gov//dep/water/ provals/t5forms.htm#inspect t5form4.doc- 06103 System Pumping Record • Page 1 of t '/COAni ION7"TALTH OF MASSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE VI\TER STREET, BOSTON MA 02108 (617) 292-5500 7 ARGEO PAUL CELLUCCI Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART A Al✓ //��( / /t / /%1Lr�Ef RTIFICATION Property Address: C7 l f /T Name of Owner )?(0 to 1 /0 ,2 r4af'� 0 V Address of Owner: Date of Inspection: �"�] Name of Inspector: (Please Print) �c+/`�1 '005-w I am a DEP approved system inspector pursuant to ection 15.340 of Trtfe 5 (310 CMR 15.000) Company Name: 4 F f r.1 t7 r) I"/ Marring Address: 2G 110 Te 44401-OZO, M4 Telephone Number: j if 3 j -v '7 ti l FA TRUDY C0XE Secretan DAVID B. STRUHS Commissioner CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:__/4/'1,114�1�Z-�'� Date: f�� -�% " oU J The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 ►� Pf'ried or Recycled Par— a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f /CERTIFICATION (continued) 'roperty Address: t Jwner: Date of Inspection: Gl f / 0 ��-� Q U INSPECTION SUMMARY: Check A, 8, C, of D: A. SYSTEM PASSES: �I have not found any information which indicates that any of the failure conditions described,in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B�.` SYSTEM CONDITIONALLY PASSES: 9, &- One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon FT ---v completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Ila ge2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: //Ow"r, / f/ " w / Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 4 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 A Property Address: Owner: Date of Inspection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this 77-#-determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. xti Liquid depth in cesspool is less than 6" below invert or available volume is less than 1l2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater then 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within: 400 feet of a.surface drinking water supply , the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15,304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Pagv4of11 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop" Address: q-) letC}�P � �'tir%o Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yeses. No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspectedJor signs of sewage back-up.; The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: / _ Existing information. For example, Plan at B.O.H. J' Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) The facility owner (and occupants, if different from owner) were provided with information on the proper maintananco-of SubSurface Disposal Systems. revised 9/2/98 pig( 5ofII O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION rroperty Address: �% !/!`Ile, ,e( .�ij f`f ��d0 V"f,� Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroo Number of bedrooms (design): ti*F Number of bedrooms (actual):_ Total DESIGN flow _ Number of current residents: 2 //i/l P,- A/u % / U Garbage grinder lyes or no): 6" g4 C� Laundry (separate system) I es or no) jf !; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):_ Water meter readings, if availatlle (last two year's usage (gpd):sC�f't� /t1 Sump Pump (yes or no): Last date of occupancy:. CCU, .f dl COMMERCIAL/INDUSTRIAL: Type of establishment:__ Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: lyes 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: Lest date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) --Ho If yes, volume pumped: J gallons Reason for pumping: 0 1 r` 4 !-._ ILA N/.[ TYPE O YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) lif yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval r � Other /3� c - APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)V revised 9/2/98 Page 6ofII U Sr .W ,. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) 1 J Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No__ Date of previous pumping: ;? Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ' f i . DISTRIBUTION BOX:Tp (locate on site plan) Depth of liquid level above outlet invert:_7—p� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ IV, i M-- (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.) r A revised 9/2/98 PaFr8(if II a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION (continued) !4 'roperty Address: 7 �/11f 0l,(J U 'F 1 '5� C Jwrw: Date of Inspection: v SOIL ABSORPTION SYSTEM (SASI:5 (locate on site plan, if possible; excly tion not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers, nu-mber:_ leaching galleries, number:_ - i " leaching trenches, number, length: E' -2 leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system:i t Name of Technology: •li"fl '°�° f ` e Comments: 11x (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Oepth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ %Lf locate on site plan) ! � Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII Dimensions: s+ s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Noperty Address: 4/ lwner: I Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) --1) 41 f revised 9/2/98 Page 10 of II a k ! • t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) operty Address: "7 ( f fQ LfJ Co �f-20 Jwner: /} Date of Inspection: .NRCS Report name Soil Type_ _ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet— Please eet ;Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) . —/Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Uq , T V- f6 fav Gam/ 9"rrZ_. revised 9/2/98 page jiorit d'. 1 955'1 I Date ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .........(71244'14:..........-u.. . C .................. has permission to perform ........ wiring in the building of........................ x ................................. at ......Y.7.. . \,Jj. 4 r,..4.0 .....RR. .... .. ...... 4orth Andover, Mas Fee ...... Lic. No. ELECTRICAL INSPECTOR Check # C d o d o, � •ci a vUr � �'' a. J maw CJ N Q ', CV WO� .p O Jc r N c) O ++ .� of f; W F7 A. N A 11 y N U N N Xb-0N ppa 0'C N 0 b p b V U V O .0b-0 w y O O. U iC w O o a� G N o N in' rp Re 4n O c;"" OW+0 tiAN rN fti 0 0 `o tib ._� co 4 y vi O b yM O' O O •bsp7b bB O Cd a' ,R' .-. O O N p, 7r ii 0 U W N U U V n p x o 0 � O .p G 0-0 cr o o 4a p d ^� o W' o p y a o 4° b .� y aq .� # o S'Q ti .p c .G U vo •� 'o o a0i P & vj on a O P,hq > y U O y 4-1 N o .� U O .�• 80 xo'o�y 4 m.2 U 2'.2 N 0 aWOi •� o 4. U •o N y QJ N o .'i W r i ..v'. O gyp. ""C' W o 3 0 W C7 Z +p.. Q� �y o `a q ami @ 0' rg . W .a 0 p -. Q' `ct w'C 'W r" N 0 - p Fla r"'�„ '"�' c"..' V .c0~d W .n pO O k ti O PQ caac�',4 coo. ookp O iC ,�.` •� O i. y O N {U� O_ O N g 0 0 N a C ,C QJ ir' N IN w a R}R} hY rn 0 :j I 0 x w 34 a f Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: .7,/ 0 V Z/ City or Town of. Alae—Y—/-, A-x1bV,P,- To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 4 7 [,�,'/ / O[11 9, dQ., Rd Owner or Tenant I / Telephone No. 1,,, 7 •_q V17 - 511o5!(e Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the.following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ n-❑ rnd. rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o etection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained p Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other No. of Dryers Heating Appliances KW yConnection ste Sec No of Devimces or Equivalent No. of Water KW, o. o o. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 46 BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: -7 / Z P'/fid Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: ..1 �YneS G,-eeh Signature (If applicable, enter "exempt" in the license number line.) Address: 5[0 Ro/!a./7-,l SY OWNER'S INSURANCE WAIVER: I am aware that the Licensee does required by law. By my signature below, I hereby waive this requirement. Owner/Agent Signature Telephone No. LIC. NO.: i7,,? `73/f LIC. NO.: e1. No., o i7 •Orr X 9',5 Alt. Tel. No.: te.,7 5rit g3j aot have the liability insurance coverage normally I am the (check one) ❑ owner ❑ owner's agent. PERMIT FEE: $ I} The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ky www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel=ibly Name (Business/Organization/Individual):�� r� ,t✓ l r/� /r-� ..LQ c Address: ?��R t-) j,%0.4 5- /' City/State/Zip: :.ha ,- / r , fo 4.0 ri Phone #: i.e, -7 59 Are you an employer? Check the appropriate box: 1. al am a employer with / b_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. []New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: R e -e r / e -s' I a - y Policy # or Self -ins. Lic. #: Expiration Date: nj / , & ,,,' -.;t c: / / Job Site Address: 47/ 1/ //C?[[> R1 n � City/State/Zip: A /,0 i Ah /9tJdQL2e r Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. B vised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance c e ge verification. I do hereby the pains of perjury that the information provided above is true and correct. o19 -,//D use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: __ Phone #: U/UJ/1137! UU. JU JU013 !130011 it Ale( Alvn6ver 4. )Jb main St /1/e oIP, A nda✓ei- "v / J I GWHr. I / HIYIJUVGIC I MART'S SEPTIC TAM SMMCE 47 RAID glgp MA 01835 978-372-7471 l rHVG U3 ADERMS GUAM ao `tA ✓07 /d far -st 5,1. L4a7n & Cry 1� ✓� � � KGs � .Sf: 15aa �rjo e - %u l /Oki s - 103 ) eckcr9vm f5no 1G.� iso 164D e +� rHVG U3 A 0 N Ul m r- < m M Z z u m � m z z < L, r- n m p I m r m Z c� M - c .D i� z 0 r 7 V z� •G N 0 LACo C', a 0 N n c > 0 c a z o z z > n z T z u �nC �� A 0 f > z > z z , A u G 0 0 D z m f 7< -< c > z 6 z z 0 0 �0z n M a > ■ , o A o 0 " c n = 0 A L - L Ll � t3 0 Lh Q c• -, d 0 4 7 el ss r -�1 R aVE,Q/.�}r Sc4.LE /"� goy -1 -Z7_____� "7 I/o) 16 -5— -- R TO: FROM: NORTH ANDOVER, MASS `�'Ee 19 7L BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at ,Za 7` /S JA1/1161u IQIdGE /�Q North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated U Vi 19_7 � / A fiS IN 01? 0 t4A) D iPl-19A-J e . of.8 ineer/RaegJnitarian � i4 � �-1Jr✓�.�T_ .W!4._R.SQ_ C i,g • __ �.G C�i9�4�` ---� ,0-- Sca.LE /"= ¢ai C SOIL PROFILE & PERCOLATION TEST DATA Tow City No.&StreetQiCS _" +�. V G- ` Lot No.� Loc./Subdiv. i'110cej /gW tom' Plan Owner �J G4��'?)�• Investigatory Gc aObserver O \�-/��.� SOIL PROFILES -DATE `51 1' Elev._ ?' Elev. Elev. 4'Ele . 0 0 0 0 � `• \ n? V � 2 2 2 2 h 3 3 3 3 4 4 4 4 MC 5 5 5 5 Benchmark Elevation 6 7 8 9 10 6 7 8 9 10 Location Datum Percolation Tests -Date H _/ 6 7 93 9 10 Pit Number G V ae 1 2 3 4 5 Start Saturation /S Soa%-Mins o -=> Start Test -Time U Drop of 3" -Time / Drop of 6" -Time Mins.lst 3"Dro 4 -2 Minso2nd 3"Drop 1-4r».-) Notes & Sketches on Back Frank C. Gelinas & Associates, North And. e^. It. I N O b 0 W S` A ■ ZO. a ZO. �s - 55z r r"071M SI, z z 0 Z D r� v rn Z 70 A � cz rn� d� d N 0 7— &V Jo co 2 •A; o.� N �V Cup AML. AF ,d \ 6)r ti \ 0 `\ \ cGi /U A-