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HomeMy WebLinkAboutMiscellaneous - 485 FOSTER STREET 4/30/2018 (2) v l E:05 EIVED � Commonwealth of Massachusetts ,� �,t City/Town of ER System Pumping Record ORTHAN�o TForm 4DE PARTMEFtT lug DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house,Right ous , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck AddressLess ^ Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town State ^��i�Code Telephone Number �1 B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition o ��Sy tem:c� Vim_ J 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio here contents were disposed: Lowell Waste Water Signitufe 9t Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Address It V S^ o s Ta-q- s-r Title of File page of Date File Open: Date File closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes T action Document/ document/ Num. Action De artment Board of Appeals - Board of Health - Planning Board - Conservation Commission -, Building Department Commonwealth of Massachusetts /Massachusetts stem Pumping Record System Owner System Location Date of Pumping Quantity Pumped: l�gallons � 4 Cesspool: No T J Yes L) Septic Tank: No U Yes System Pumped by: gareQort 5,,&Vvv4ed License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � d DEPARTMENT OF ENVIRONMENTAL PROTECTION A M / C Y� TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_485 Foster Street _North Andover_ Owner's Name: Lynne Tortora_ Owner's Address: 485 Foster Street_ North Andover,MA. 01845 Date of Inspection:_10/17/2000_ Name of Inspector:(please print) Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma. 01810_ Telephone Number:_(978)475-4786_ 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 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: _X Passes Conditionally Passes Needs Fqrther Evaluation by the Local Approving Authority •ls Inspector's Signature: Date: _10/17/2000_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After permit from Board Of Health,replacing broken pipes,inspection from Board Of Health,system now passes Title 5 Inspection. ****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. F ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION F �O TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_485 Foster Street_ _North Andover_ Owner's Name: Lynne Tortora_ Owner's Address:_485 Foster Street_ _North Andover,MA. 01845 Date of Inspection._10/07/2000_ Name of Inspector:(please print) Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma. 01810_ Telephone Number:_(978)475-4786_ 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 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 —X–Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: Date: _10/07/2000_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:Needs pipe replacement from tank to D-Box approximately 10'long. ****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. Page 2 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 485 Foster Street_ _North Andover_ Owner:_Lynne Tortora_ Date of Inspection:_10/07/2000_ 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: _X_One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.Needs ten feet of pipe replacement from tank to D-Boz. _N_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. ND explain: _N_ 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 distribution box is leveled or replaced ND explain: _N 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_485 Foster Street_ _North Andover— Owner: Lynne Tortora_ Date of Inspection:_10/07/2000_ 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 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_485 Foster Street_ _North Andover— Owner: Lynne Tortora_ Date of Inspection:_10/07/2000_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _N_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool N— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _N_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow _N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ N Any portion of the SAS,cesspool or privy is below high ground water elevation. N— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _N_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _N_ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_485 Foster Street _North Andover— Owner: Lynne Tortora_ Date of Inspection:_10/07/2000_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Y_ _ Pumping information was provided by the owner,occupant,or Board of Health N_ 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? N_ Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Y Was the facility or dwelling inspected for signs of sewage back up? Y Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _Y_ _ 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: Yes no _Y _ 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)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_485 Foster Street _North Andover— Owner: Lynne Tortora_ Date of Inspection:_10/07/2000_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_600_ Number of current residents:_2 Does residence have a garbage grinder(yes or no):_No Is laundry on a separate sewage system(yes or no): No_ [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no):_No Water meter readings,if available(last 2 years usage(gpd)):_On well Water_ Sump pump(yes or no): Yes_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped last year,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500 gallons--How was quantity pumped determined?_Measured tank size_ Reason for pumping:_Inspect tank&tees TYPE OF SYSTEM X 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 14 Years.6/16/1986.As built plan._ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION(continued) �I Property Address:_485 Foster Street_ _North Andover— Owner:_Lynne Tortora_ Date of Inspection:_10/07/2000_ BUILDING SEWER X (locate on site plan) Depth below grade:_18" Materials of construction:—X—cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line:_100'_ Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall.3"PVC in house. No leaks._ SEPTIC TANK: X (locate on site plan) Depth below grade:_6" Material of construction:—X—concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth 6"_ Distance from top of sludge to bottom of outlet tee or baffle:_21"_ Scum thickness:_6" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_15" How were dimensions determined:_Subtract scum&sludge depths to tee length._ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Pumped septic tank.Inlet&outlet tees ok.Depth of liquid at outlet invert.Snaked outlet pipe to d-box,found broken&collapsed pipe._ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 485 Foster Street North Andover Owner:_Lynne Tortora_ Date of Inspection:_10/07/2000_ s ection locate on site plan) TIGHT or HOLDING TANK: (tank must be pumped at time of m p )( p ) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): if resent must be o ened locate on site plan) DISTRIBUTION BOX: ( p p )( P ) Depth of liquid level above outlet invert:_0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-box level&distribution equal.Evidence of carryover,pumped d-box to clean.No evidence of leakage._ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): A TT\T lvT• T T1TP'ITTI PITTA IT Tl/�Tl•R 1TAT TAT TTAT iT�TT •T\TT • (V l'I T1!'I fY1 tT\1TTfY Page 9 of I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_485 Foster Street_ _North Andover_ Owner:_Lynne Tortora_ Date of Inspection:_10//7/2000 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: _X_ leaching trenches,number,length:_5 Trenches 46'long_ leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface._ 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 10 of 11 SYSTEM INFORMATION(continued) Property Address:_485 Foster Street _North Andover_ Owner:_Lynne Tortora_ Date of Inspection:_10/07/2000_ I. SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. N House To Well Driveway Garage A C Porch 100' B 1 Septic Tank 2 Broken Pipe Ato1 = 14' 3" Ato2=21' A to D-Box=46' B to 1 =8' 46' B to 2= 12' D- Box C to D-box=44' v A OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM T 1"r r d" Page 11 of 11 • SYSTEM INFORMATION(continued) Property Address:_485 Foster Street_ _North Andover— Owner:_Lynne Tortora_ Date of Inspection:_10/07/2000_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_4 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_6/16/1986_ Observed site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain:_As per design plan_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation:_As per design plan._ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 485 Foster Street Owner: Lynne Tortora Date of Inspection: 10/07/2000 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Yeil J. Bateson Bateson Enterprises, Inc. J Commonwealth of Massachusetts , Massachusetts System Pumping Record System Owner System Location Date of Pumping: �d �-��-- Quantity Pumped: 11"�gallons Cesspool: No Yes [] Septic Tank: No [] Yes System Pumped by: 64&44W License# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: ? 7 Town of North Andover, Massachusetts Form No.3 t NORTH BOARD OF HEALTH 9 ♦i - __A� DISPOSAL WORKS CONSTRUCTION PERMIT $BCH SE Applicant AME ADDR SS TELEPHONE Site Location ` f, Permission is hereby granted to Construct ( ) or Repair an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CH�f ,BOAR EALTH • Fee D.W.C. No.L�?D_� i t APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: 0 S Fd S 7z rS Q/d- � a✓fes LICENSED INSTALL /� �� rg �-2 Sd,✓ SIGNATURE: TZ 7� TELEPHONE# 'SO 5 " a '7 3 CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? No Floor Plans? Y s No Approval Date: i, r is INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at /Y'.S /'as7- 2 s4 relative to the application of dated for plans by and dated with revisions dated I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed—generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from engineer must be submitted to BOH,after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. . c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersi d Licensed Septic Installer �� - Date: AD— BOARD OF HEALTH r ao kn' 1 �c Town of North Andover,Mass . Permit, # �j Date 19 APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well (_vf. Application fs made to install (t'' ump system'. LocatiA dress Lot # Owner © Address �}�( ; Tel .�� �' Well Contractor6hl--C lifuA dress I10Ls, � e1 RQ871/2 Pump Contracto Address w1y) rim, NTel . WELL CONTRACTOR (To bencompleted at time of pump test ) Type of Well Well used for. ) �� Diameter of Well_ Size of. Casing Depth of Bed Rock Depth casing into Bed Rock Was Seal Tested? Yes M No (_) Date of Testing Q De-pth ••o-f 14,R3 1 -� ' Well Ended in Whax- Material Depth to Water �� Delivers Gals .Per Min. for 4 hours Drawdown140feet after pumping —hours� at _ . . GPM Date of Completion lgna ure We ontractox ����*sir-'kx�xXkx:::';•�:;st:;:�%i%>.�#�c'xkx�xsY�k:::;::k:;;::;::;: :;:;:;�;-k-k-�-:'c:;-��-�::-�:;-k:::;xX�;:k�k�7r*���c�*k•�r PUMP INSTALLER (To e• f ed in before installation) Size & Name Pump u( �0 ° _-Pump Type Used Water Pump Delivers_ -GPM Size of Tank V-00 Pipe Material Used in Well : Cast Iron (_) Galvanized (_) Plastic (t-j' Well Pit (_) or Pitless .Adapter (L-f Was sleeve -used to protect pipe? Yes (^) NOM Type or Name We Sea14l Date *tk*�rir �hrllr �r ** Vr* +�r�M►M * *tktktk�ktk*ski*fit �4tittiMtiYtiYti'r�r�r��st `:SPF.19 0, W-1 Date Water analysis repor-t 'submitted to Board of Neal-th Date release given tD owner of record & Bldg. Insp �Q.�r' 1 !•74� SJ.S y Health Inspector BOARD OF HEALTH f Town of. North Andover,Mass . Permit Date 4- - ---APPLICATION FOR WALL & PUMP PERMIT Application is he eb made for permit to drill a well (� Application is made to installer a ump ystem. Location, Addre s ' Lot # -dwner jxeZvr os Tel . Well Contractor Address. �,�. Tel . �c�' Pump Contractor Addres$ Tel /-��� -- WELL CONTRACTOR (To Abec le , t time of pump st ) w Type of Well = ICi Well used, 'for Diameter of Well Size of `Casing Depth of Bed Rock` Depth casing into Bed Rock tel/ Was Seal Tested? Yes ( No (-) Date of Testing Depth of We'll � Well Ended .in. What Material Depth--to--Water --- Delivers_-6als-.Per Min. for 4 hours � Drawdown feet ter pumping-� hours at G Date of Completion / Sign ure well Contractor PUMP INSTALLER (To be filled in bre /stallation) () 1 Size & Name Pumo �%,l�/f � G f P„fi Tz►.,e LTCB 1 F y Water Pump Delivers_ GPM Size ' of Tank11.1 Pipe Material Used in Well': Cast Iron ( ) Galvanized ( ) Plastic Well Pit (-) or Pitless Adapter - Was sl ve used to protect pipe? Yes ( ) N ) pe o N W Se Date 4t9t tilt�k tk'�r tk�r�r tk s4'�r�r tk 14 tk k tk tM thr tk tk tk�r ti4 ti4 SY tk�4r tM sk tM t4�Ir tk tip s4�r sit sir sk ti►t :�,;:';n::c-�.�:;;;is�,�e,tic,,,I z��:i T D �;�r �r�F i�Thr 9h��l'1k 1k Date Water analysis report submitted to Board of Health Date release given m owner of record & Bldg. Insp Health Inspector ........._ ._ ... . A .b� Water Pumps 7amn p� Sewage Pumps PUMP CO. Artesian Wells 9J RT.28 WINDHAM,N.H.03087 C' Water Softeners `OO R SE [603]898-4232 0 [603]627-9533 o [617]887-5888 Water Tanks Water Testing MILLTOWN REALTY TRUST Pump Parts 95 MAIN STREET NO. ANDOVER, MASS. 01845 Motor Controls Switches OWNER'S NAME OR SAMPLE LOCATION: Guages LOT#2 FOSTER ST. NO. ANDOVER Softener Salt Resin Cleaner WATER TEST RESULTS 12/9/85 TEL NO 685-7633 Rust Remover HARDNESS 68.4 (0-50 REG STANDARD) Potassium Permanganate IRON .5 (0--.3 REC STANDARD) MANGANESE 0 (0—.05 REG STANDARD) Soda Ash HYDROGEN SULFIDE 0 (0—.01 REC STANDARD) Ph(ACIDITY) 7.5 (6.5-7.5 REC STANDARD) Lawn Sprinklers TURBIDITY 1 (0-20 REC STANDARD) CHLORIDES 18 (0-150 REC STANDARD) Chemical Feeders COLIFORM BACTERIA NEG (0 REQUIRED STANDARD) NITRATES 0 (0-10 REC STANDARD) Tank Alarms NITRITES 0 (0-10 REC STANDARD) SODIUM 11 (0-150 REC STANDARD) Hoist Service Portable Pump Pullers TESTED BY kycYc�cycve�c)kyck9crcYckJ�7� ycyckk9ciY;tY<5kXc5kyc�cycycaYvcycvcYcvcYYcaryck Air Compressor Trencher ABOVE TESTS MEET REQUIRED STANDARDS AND BASED ON THESE, Pipe Pullers WATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION. THERE ARE OTHER LESS COMMON MINERALS WHICH CAN AFFECT QUALITY OF WATER. Goulds Aermotor Jacuzzi Aquatron Well-X-Trot Aqua-Air �" � ,.1 ,� �-." `, ,,1 1 ''� 1 1, �1 ��� � � `�, 1 1 1 � _ 1 i '1 I 1 1 � � , 11 BC#ARD OF hEALTK' --No.Ando tre r , Nra. s . t SUBSURFACE DISPOSAL DEMC3N CHECK LIS' L-LiOL"N KE IBJ Vl/� d �L' LOT # 2 F:6STEK 5T- APPROVED TAPPROVED DATE 5-1-56 / DISAPPROM DATE Provided: /n Reasons: Title V FAIL OK Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area dimensions lot #,abutters Ib location and log daep observation hoes-distance to ties c location and results percolation tests-distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements vith n 1001 of sewage disposal system or disclaimer-Planning Board 'files (3) known sources of water supply withizr 2001 of sewage disposal d system or disclainer (k) location of any proposed well to se= -e lot-1001 from leaching facili• (1) location of water lines on property-'. 01 from leaching facility (m) location of benchmark " (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximam ground water elevation in area sewage =disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks - (a)(a) apacit .es- 5U or :flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s ope greater 0.08 Reg 10.11 (b) sump P- Rb ofHFA T i-I L-or z E( ST : NoTT'H /Jti l���l�, MA, jbwtJ 0 wEc — AP 0�0vcD1YJ(G S S 5EPT'I C Sy sTE,A J,�-1 r- .J ,bPPi�ovC"v D,dr�' /PR�OuIN6 /uTtlai�)TY �o�J(JITio�vs �15APPt�v� 14-1 E R>~45oNS D ---� stFT(c, SVSTEM Ijs )otL,4Ti(--\Aj C-)"V4T(olJ V4 S [� �f4►L �wAL i�15PFGjlonJ ' PPRO\JED /JTC , I- �P�rv�vwG �1�Ttor�iry 4��IT�p/J,QL I�5(T�.j 1ptiS X11-A►�y) aSAPr'�dvi;l� DA Te- FML CFML APPIROVAL APP)30v(A)G /6 u iNn P, / l � � -acv►C�a�.1-" r.a Cv1-7 cam. ti i Q O 0 � 1 �y 1 � 1 lb cs ti . . a W I 1 I f��`Huts 0 �II� ^rye C,, �` I-�,��• • Jay (� i) LC?r- Z� COS S