HomeMy WebLinkAboutMiscellaneous - 5 CHRISTIAN WAY 4/30/2018 (2)Town of North Andover, Massachusetts
BOARD OF HEALTH
J JiP 19
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Form No. 2
Applicant O.il.e.,t Test No.
Site Location Le `. 1 5 akJl c .C)-4--1 (i /► 1 LUf 4-'
Reference Plans and Specs OL,V .� Join
ENGI EER DES N DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee lip
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 43
I"" EIVED
Commonwealth of Massachusetts • 0 3 2015
City/Town of TC"' ' NORTH ANDOVER
System Pumping Record NORTH ANDOVEIR'`'r'DEPARTMENT
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When titling out 1. System Location:
forms on the
computer, use
only the tab key Addre
to move your d
cursor - do not City/Town
use the return
key System Owner:
Name
__._ CS, r
Address (if different from location)
City/Town
Zip Code
State Zip Code
9 7 — (4G `- 3ff,
Telephone Number
B. Pumping Record �/
1. Date of Pumping 70.- / 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4. Effluent Tee Filter present? ❑ Yes RN -CT
5. Condition of System:
6. System Pumped By:
Wind River Environmental
Name 163 Western ve.
lGlowanter,-_MA O1930_ .
Company
7. Location where contents were disposecj;-
Signature of Hauler
Gallons
If yes, was it cleaned? ❑ Yes ❑ No
gnZL
Vehiclelicense Number
Date
Signature of Receiving Facility Date
15form4.doc• 03/06
System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
15form4.doc• 03/06
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A„ J 0 / 2014
A. Facility Information
1. System Location:
5_ e_lie-iNian
Address
dovtt,..
City/Town
System Owner:
Name
Address (if different from location)
City/Town
S14
tate
Zip Code
State Zip Code
epho a Number
B. Pumping Record
1. Date of Pumping - Date �1 GPI -- 2. Quantity Pumped:
1600
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): l�
4. Effluent Tee Filter present? ❑ Yes D9N,o. If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst m•
0747.(
6. System Pumped By:
Name
Compan
were disposed:
Signature of Hauler
Vehicle License Number
Antkom MA.
1,/5))1 _
Date
Signature of Receiving Facility Date
System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOV
Form 4
pKt,:.. Cl .Q i O
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1.
City/Town
2. System Owner:
1VI.163c t, �unY�
Name
System Location:
5 C.hr\ eiY,_ yNc
Address
Noah oVc,- - - H - - -
State
Zip Code
Address (if different from location)
City/Town
State Zip Code
b86-388T
Telephone Number
B. Pumping Record ''
1. Date of Pumping o I - 5 _ i 0 2. Quantity Pumped: Ga1o5Ob
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [> ' No If yes, was it cleaned? ❑ Yes L "No
5. Condition of System:
6. System Pumped By:
tm GQ\\Q
Name
Vehicle License umber
Wind -Ri'r X EnViconViC6cd
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of t4Dfl'% olocwim
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
vtrm
Ad re , ANDOVE I MACity/Town State Zip Code
2. System Owner:
C'" li chge, �1Ann
Name
ti Address (if different from location)
City/Town
State Zip Code
9-7S- bb- 3FF$
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q' Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ["No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
J►m GQ\\c
Name iNtocwilk
Company
7. Location where contents were disposed:
1bb1°)
Vehicle License Number
G.L.S.D.
Lawrence, MA.
Signature of Hauler
/4( (®5
Date
Signature of Receiving Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
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.
****************Applicant fills out this section*****************
nine5 L.r 171/1 4,417
APPLICANT:
Phone(60-) i `'`s-�
LOCATION: Assessor's Map Number (dill) Parcel ILES
Subdivision TVfli.& Lot(s) -ALE-
Street aln t46h
************************Official
RECOMMENDATION OF TO AG
on Admistrator
se
St. Number _5
Only************************
Date Approved SO-3
Date Rejected
Comments
u,v1rfrAlElt-
Town Planner
Date Approved 4j040t��
Date Rejected
Comments
Food Inspector -Health
Septic Inspector -Health
Comments -704f4:-
Date Approved
Date Rejected
Date Approved 7/ 42T
Date Rejected
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
Gori
Cr IS Tc o J
747
above, clmuAAI f & y
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.
************�****Applicant fills out this section*****************
APPLICANT: Dl lid G'4c5K k) Phone & ' --1 t1/
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s) 8
1
Street C-�_15klu G!✓�
St. Number 5
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector -Health Date Rejected
Date Approved %//1/�`%
Septic Inspector -Health Date Rejected
Comments � )Vi- /AiL
Public Works - sewer/water connections.
- driveway permit
Fire Department
Received by Building Inspector Date
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Town of North Andover, Massachusetts Form No. 1
BOARD OF HEALTH
19
APPLICATION FOR SITE TESTIN /INSPECTION
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME
ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN, BOARD OF HEALTH
Fee Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
CNKi5ronl wQy (w,v5 cb1L
( 4Rr) OF' 1160-TH
AJOrnH ,QNPUEI�, NLG.
A ??Li c4tUT
i
WATER SUPPLY - roWnl 0 WEU- APfiouEDDOTG
5El fl c SY STEM PES► &J
D,a%� I2•z3-g�
D15,4n7KOVED 'ATE
REASONS
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FINAL I;USPEErlonu
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AppRoviA)G 40 r logi
PATRICK J. DONOVAN ASSOCIATES, INC
"CLAIM AND LOSS ADJUSTMENTS"
P.O. Box 110
Wakefield, MA 01880
(617) 245-5540
FORM OF NOTICE OF CASUALTY LOSS TO BUI
UNDER MASS. GEN. LAWS. CHP. 139, SEC. 3B
TOWN OF i%"ORTH Ai ^OVER/
BOARD OF
1
RIR25;
TO: Building Commissioner.or
Inspector of Buildings
City or Town Hall
RE: Insured:
Property Address:S C,HQ. 1R4) \AJA,
A p o0o-P-1 MA Q ?
Policy Number: 1j ` lU ) Lid-.3)
Loss Type: D it-0/0
Date of Loss: / — —
Our File Number: t,c,A P zZ S6
Claim has been made involving loss, damage or destruction of the above -
captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws,
Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen.
Laws, Chapter 139, Section 3B is appropriate, please direct it to the
attention of the writer and include a reference to the captioned Insured,
location policy number, date of loss and file number.
Adjuster
Donovan Associate's/, Inc.
Wakefield, MA
On this date, I caused copies of this notice to be sent to the persons named
above at the addresses indicated above by first class mail.
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUMS
Commissioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CBITIRCATION
Property Address: 5 Christian Way, North Andover Name of Owner. Alfred Gaskin
Address of Owner: 5 Christian Way, North Andover, MA. 01845
Date of Inspection: 6/13/2000
Name of Inspector: Neil J. Bateson
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Bateson Enterprises Inc.
Mailing Address: 111 Argilla Road Andover, MA 01810
Telephone Number: (978 ) 475-4786
CERTIFICATION STATEMENT
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:
Date: 6/13/2000
The System Inspector shall 't a copy t s inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a ared 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 After permit from Board of Health, replace broken & collapsed
pipe & Inspection from Board Of Health, system now passes
Title 5 Inspection.
TC
,JUN 19
revised 9/2/98 Page I of 11
Printed on Recycled Paper
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. SMITHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIRCATION
Property Address: 5 Christian Way North Andover Name of Owner: Alfred Gaskin
Address of Owner: 5 Christian Way, North Andover, MA. 01845
Date of Inspection: 5/27/2000
Name of Inspector: Neil J. Bateson
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR I5.000)
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on -site sewage disposal systems. The system:
Passes
X_Conditionally Passes
N - - • . Further Evaluation By the Local Approving Authority
Fail
Inspector's Signature:
Date: 5/27/2000
The System Inspector sh I • it a copythis inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If he 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 I of 11
Printed on Recycled Paper
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
INSPECTION SUMMARY: Check A, B, 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:
X One or move 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. Outlet pipe repair & flow levelers in d-box.
Indicate yes, no, or not determined (Y, N, or NO). 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 leveled 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 Page 2 of 11
.1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5 Christian Way , North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
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 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.
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 3 of 11
.t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
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
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(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 1 00 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile
organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS -
You must indicate either "Yes" or "No" 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 11 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 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_X_ Pumping information was provided by the owner, occupant, or Board of Health.
_X _ 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.
_X_ As built plans have been obtained and examined. Note if they are not available with NIA.
_X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout.
_X _ All system components, excluding the Soil Absorption System, have been located on the site.
_X _ 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:
_X Existing information. For example, Plan at B.O.H.
_X_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[I 5.302(3)(b)]
_X_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address : 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow _150 _ .g.p.d./bedroom.
Number of bedrooms (design):_4 _ Number of bedrooms (actual_4_
Total DESIGN flow _600 _
Number of current residents: _5_
Garbage grinder (yes or no): _ No_
Laundry (separate 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. March 97 to March 99 = 44,000 ft3 x 7.5 = 330,000 gals. / 730 days = 452 Gals/ Day
Sump Pump (yes or no): _No _
Last date of occupancy: _Current_
COM M ERCIALII NDUSTRIAL:
Type of establishment:
Design flow: arid ( Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: Pumped two years ago
System pumped as part of inspection: (yes or no)_Yes _
If yes, volume pumped: _1500_gallons
Reason for pumping: Inspect tank.
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 13 Years old. 7/28/1987. As built plan.
Sewage odors detected when arriving at the site: (yes or no)_No_
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
BUILDING SEWER: X
(Locate on site plan)
Depth below grade: 15"
Material of construction: _X_ cast iron _X_ 40 PVC other (explain)
Distance from private water supply well or suction line:
Diameter :4"
Comments: 4" Pvc thru wall. Unable to see piping in house, finished cellar.
SEPTIC TANK:X
(locate on site plan)
Depth below grade: 3"
Material of construction: X_ concrete _metal Fiberglass Polyethylene _other (explain)
If tank is metal, list age _Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 10' x 5' x 4' x 7.5 = 1500 gallons.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 21°
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle:18"
How dimensions were determined: Subtract scum & sludge depths to tee length.
Comments: Pumped septic tank. Inlet tee ok. Outlet tee corroded on top. Depth of liquid at outlet invert. No evidence of leakage. Snaked outlet pipe to D-box,
found broken & collapsed pipe.
GREASE TRAP: None
(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:
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
TIGHT OR HOLDING TANK: _None_ (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete metal _Fiberglass Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes _ No
Date of previous pumping:
Comments:
DISTRIBUTION BOX.:_X_
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments: D-box level & distribution not equal. Installed flow levelers. D-box cover broken, replaced same. Evidence of solid carryover, pumped d-box to clean.
No evidence of leakage.
PUMP CHAMBER: _None , gravity system_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
Revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued))
Property Address: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions: I field 25' x 46'
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments: Soil ok. Vegetation ok. No sign of ponding to surface.
CESSPOOLS: None
(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 (cesspool must be pumped as part of inspection)
Comments:
PRIVY: None
(locate on site plan)
Materials of construction:
Depth of solids:
Comments:
Dimensions:
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
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)
Septic Tank
D-Box
House
B Water Meter
Garage
Ato1=33'4"
Ato2=40'
A to D-Box = 53'8"
Bto1=17'6"
Bto2=23'9"
B to D-Box = 32'7"
revised 9/2/98 Page 10 of 11
Driveway
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Christian Way , North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
NRCS
USGS
SITE EXAM
Report name
Soil Type_
Typical depth to groundwater
Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 4 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_X Obtained from Design Plans on record
_X Observed Site (Abutting property, observation hole, basement sump etc.)
X Determined from local conditions
X 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) As per design plan.
revised 912198
Page 11 of 11
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: 5 Christian Way, North Andover
Owner: Gaskin
Date of Inspection: 5/27/2000
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.
Neil J. Bateson
Bateson Enterprises, Inc.
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
6/13/00
This is to certify that
the individual subsurface disposal system
constructed () or repaired (X )
by
Todd Bateson
at
5 Christian Way
Pipe Repair, Tank D-Box Only
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
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Permission is hereby
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: Ca — Co _ o U
CURRENT INSTALLER'S LICENSE=
LOCATION: Gk r- t-S 1
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LICENSED DIST. R: �4-�-e soy✓
SIGNATURE: TELEPHONE % — S75-J ,
CHECK ONE:
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NEW CONS 11ZUCTION:
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IF NEW CONSTUCTION,I. LEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
S75.00 Fee Attached? Yes _— No
Foundation As -Built? Yes No
Floor Plans? Yes .No
Approval , t(p/7/616
PP _ �,XJ/L���2� Dae:
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the property
at S Glks,'s1./..i 1/41„/-Ay relative to the application of % r>- \-\4.-/-c sv' ,
dated 4 - 4 - �o 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.
I)
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.
Unders : e• icensed Septic Installer
Date: 6 - 6 d d
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
6
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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
RECEIVED
DEC 0 4 2009
TOWN
NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other orms 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1.
System Location:
h65k1c
Addres
I orr\n Ao1 v
City/Town
2. System Owner:
M;c1QCI 'unn
Name
MI
State
Zip Code
Address (if different from location)
City/Town
State Zip Code
q77-bS1)-
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Condition of System:
VSeptic Tank ❑ Tight Tank
1500
Gallons
❑ Grease Trap
Goo
If yes, was it cleaned? ❑ Yes [2/No
6. System Pumped By:
GQU cAn4
Name won r
�nel Ive'i tflV►conmCnQ\
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
7bb79
Vehicle License Number
r, (IA r7N
•ter..
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1