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HomeMy WebLinkAboutMiscellaneous - 520 BOSTON STREET 4/30/2018 (2) \� ` r � ` V 1 SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? ESD NO TYPE OF CONSTRUCTION: NEW EPAIR NEW CONSTRUCTION: FIED PLAN REVIEW YES NO GOND APPROVAL YES NO M FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT PAID? YES NO DWC PERMIT NO. 76 INSTALLER: BEGIN INSPECTION ES O: EXCAVATION INSPECTION: NEEDED: PASSED ?/D / BY� CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: FINAL GRADING APPROVAL: DATE BY �� FINAL CONSTRUCTION APPROVAL: DATE: BY D /�/'t8 � �1�,1�1T/Qi(1.9� ���•� /�� tJ c� oG �ysrEM . Co,vs7-�evcTr©.c.� i Commonwealth of Massachusetts City/Town of REC wED System Pumping Record Form 4 P1AY 19 2014 V DEP has provided this form for use-by local Boards of Heal .`O#1list_fbrAgTi�a '� V6 but the information must be substantially the same as that provided e— E e ore �"t ' 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 Nous Le Rig ear of hous Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Dao City/Town State Zip Code 2. System Owner. Name' Address(f different from location) City/Town Code Telephone Number Gi t B. Pumping Record t Lf 1. Date of Pumping gate 2. Quan' Pumped: Canons 3. Type of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No; ' 5. Condition of,Sys l� 6. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati ere contents were disposed: Lowell Waste Water 15 Sig HauleiU Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Address A( Ste—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 action Document/ document/ Num. Action Department Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building, Department TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) go DATE OF PUMPING: �-DQUANTITY PUMPED /'GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: - JEAN � PITS MIN 660 LEACHING MIN 1 (131X16' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60 ' X 601 ) MIN 13 ' X 16 ' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 660 GPD 900 ft2 BED PERC RATE FASTER THAN 20M/IN GW MIN 4 ' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? DIST LINE SLOPE .005? >31COVER-VENT SCH 40 MIN 12" COVER RATE LDG X 660 = = TOTAL ft2/G REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITYgpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. t� GWO/4Min. 1 ' below inlet) HWL LWL CHECK VALVEy BLEEDER HOLE.X MANUAL OP. SWITCH i r Copyright 0 1993 by S.L.Starr wx" pllalfpli, p$, r Y" � 11/11 /111 - • •. fr .� r 111 1111111 / , 11 11 111111 -, 1111 11!!111 1! 11 1111111 �� •► - !1111111111 _ 1 X1110111111 !11111 1 1''illi��r 011111 1 1111111111111 : ,: 1 �1� I11J1601111111 ¢ 1 1 1 111111111111 h - _ 111 11111111111111 .- ��£ 111 1111111111111111 . ti .; 11 1111 11111111111111111: "} �_ 111 111111111111111111 � ` _� 111111 111111111111111111 � ' - � 1 111111111111111111111111111 X.' � � 1 1111111/1 111111111111111 ..µ 1 11111//1 111111111111111 . " ' N��: 1 111 1111111 1111111111111 .' �� 1 11111 1111111111111 ; .. ��: '� 1 1111 111 111111111 ; ° .1 1111 111 11 111111 ,. { : Town of North Andover, Massachusetts Form No.2 f NORTp BOARD OF HEALTH 41 U o � p DESIGN APPROVAL FOR Acm SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 0j-k�—S %- L-,-2 e ,tLAA47estNo. Site Location. '52-0 0 Skln S& Reference Plans and Specs. • ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. MAI RMAN,BOARD OF HEALTH : Fee Site System Permit No. 13 CO-HONE #ALL) FOR Ss DAT F U TIMEG'3 P.M;. OF � PHONED RNED PHONE -AETUYOUR CALL AREA CODE NUMBER EXTENSION 9aASEGALL MESSAGE C J� WILL CALL AGAIN CAME TO SEE YOU WANTS TO SEE YOU SIGNED Ll V TOPS IV. FORM 4003 2-201 S S i PLAN REVIEW CHECKLIST ADDRESS ��(� �S ��� ENGINEER GENERAL 3 COPIES STAMP LOCUS X NORTH ARROW SCALE CONTOURS PROFILE °' SECTION BENCHMARK b� SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS WATERSHED?14 DRIVEWAY L-"" (Elev) WATER LINE FDN DRAIN SCH40 TESTS CURRENT? SEPTIC TANK MIN 1500G ,-� . 17 INVERT DROP GARB. GRINDER /VO(+200% EDF) 25 ' TO CELLARA� MANHOLE TO GRADE ELEV GW D-BOX SIZE # LINES 4- FIRST 2 LEVEL STATEMENT INLET/09,00-"- OUTLET/Dd) _ (2" OR . 17 FT) TEE REQ'D? LEACHING D ,�� I, MIN 660 GPD? RESERVE AREA �/4 ' FROM PRIMARY? 2% SLOPE 100 ' TO WETLANDS 11-11 100 ' TO WELLS `� 4 ' TO S.H.GW 35 ' TO FND & INTRCPTR DRAINSO/(�'- 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY .i' MIN 12" COVER FILL? (25 ' if above natural elev; 101if below) BREAKOUT MET? �-J TRENCHES f�J 1 MIN 660 gpd SLOPE (min . 005 or 6"/100 ' ) (/ >3 'COVER -VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) L� IS RESERVE BETWEEN TRENCHES? L- IN FILL? MUST BE 10 ' MIN. 4" PEA STONE? Q BOT 9100_ X LDNG + SIDED X LDNG = TOT (L x W x #) (G/—ft 2) (-BxF7 (G/ft2) �x� Xd/y-* . fright @ 1993 by S.L.Starr 1 `. ',.i..Y i` '4i v .,. �.,'�."•=. ,7,�`r:•.`'t�, y^2.45, _ .lii; +»,� ti �3 N., `i`-i�'R' Z:}¢A �S"� i�.� �a �i<�. 00. s�ti♦ r...�.`t\''t?.�,lr t..,i.,L,: \` ..� , Hca �,.. 1iZ:."�•�� ���:.'x", t, .,. .a'��,.� at +,' r , -q 1,43 Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH _ t NORTH 19 . OL F 9 DISPOSAL WORKS CONSTRUCTION PERMIT „o ,SSACHUSES Applicant ADDRESS TELEPHONE NAME Site Location E �`'i� '►J c7 Permission is hereby granted to Construct ( ) or Repair 0 an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. T -2 HAIRMAN,BOARD E HEALTH l D.W.C. No. Fee 1, FORM 4- SYSTEM PUNIPL\G RECORD 1 aNp� Commonwealth of Massachusetts Massachusetts System Pumping Record 'stem Uwner Systern Location Date of Pumping: i Quantity Pumped:/Q gallons Cesspool: \0 Yes ❑ Septic Tank: No ❑ Yes System Pumped by- 7�� License #: Contents transferred to: �� © r Date Inspector Board of Health SEPTIC SISTER North ver Haas., ,5 zo S( Ills- INSTALLATICK CHECK LIST LCT' O . . OV�D DATE HISAPPROMI XCAVATICH Cb FAIL easpnst r FAIL OK � ��►i? 1. Distance To: ti� }�T( 1/�til= (7- !fixOFF , �x�sr s � - a. Wetlands T/�jc FORA Cie 00 5WL OLU b. Drains c.. Well ( Gf"l,P(r5 S�G . HUS 2. Water Line Location (�SrA �, SdODY GOSCAJ 3. No PVC Pipe .' �. Septic Tank a. _Tees --Length & To Clean Out Covers. b. Cement Pipe to Tank On Both Sides of Tank- 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Equal Amount c moist , � 3E� ' c. No Back Flow - +: 6. ' Leach Field or Trench E a. D nenslons b. Stone Depth ;. . c. Capped Inds d. Clean Double'Washed Stone' 7. Leach Pits i' a. Dimensions ;r b. Stone Depth c. Splash Pads ------ d. Tess e. Cement Pipe to Pit - Both Suedes f. Clean Double Washed Stone 1= ' #�# 8, No Garbage Disposal 9. -Final Grafi Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location - b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations e: Water Table :F t ,K FLYNN Assoc. P. c. CIVIL, SANITARY and CONSTRUCTION ENGINEERS P.O. Box 569 Plaistow, New Hampshire 03865 Tel. (617)686-3559 April 25, 1984 Mr. Michael Rosati Board of Health 120 Main Street North Andover, Mass. 01845 :e: Subsurface Disposal System Repair for.Cullinan, 520 Boston Street Dear Mike: On April 23, 1984, you and I conducted soil observation/spring ground water determination tests at the referenced site. Two test holes were excavated; hole #1 within the upper plateau of the property and hole #2 in the slope below the upper plateau and adjacent to the existing subsurface disposal system. The following results were obtained. Hole Number 1 2 Depth of: Top and Subsoil 0' - 1' 0' - 0.5' Parent, sandy till with stones 1' - 10' 0.5' - 8.5' No ground water was observed in either hole. The weather was clear. After each use of the existing system, the water would immediately displace out of the system and onto the ground. Based on the above, you and I decided the following: 1. Slope ground water was riot intruding into the existing system, since no ground water was found in hole #2 even at a depth below that of the existing system. The existing system has apparently failed. 2. Unless a cause for improper operation is determined prior to construc- tion, the system will be repaired by: a. Installing a precast concrete pump chamber on the outlet end of the existing septic tank. b. Installing a submersible sewage pump, related panel and electrical connections, and a light and bell high level alarm connected to a separate circuit from the pump. The pump is to be a Goulds model 3881 series WP05115 or approved equal. i r Mr. Michael Rosati April 25, 1984 Re: Cullinan Page 2 c. Installing a check valve and 2" diameter PVC forced main at a depth of not less than four feet to a distribution box in the upper plateau. Inlet to the distribution box to have an energy reducing "T" attached. Outlet pipes to be 4" diameter solid PVC pipe laid at a slope of 0.02 to two leaching chambers. d. Installing two concrete leaching chambers in two leaching pits. Each chamber is to be a Shea Concrete Company shallow rectangular pit (5'± by 8'±) or an approved equal. Each pit is to be excavated such that four feet in width of 3/4 ' - 12' double washed stone surrounds the chamber from the top of the inlet pipe to the bottom of the chamber. Pits are to be spaced so that their closest walls are at least 26' apart. Pits are to be located not closer than 30' from the top of slope. The bottom of the pits are to be 5' below existing grade. As you requested. I am submitting this letter in lieu of plans describing the repair. A copy of this letter is being sent to the owner so that they can proceed with the repair. The installer will have the responsibility of con- tacting the Board of Health to insure proper inspection. Due to the nature of this repair and the many inherent indeterminable variables, no warranty of the repair design or its efficacy is expressed or implied by this design. Please contact me should questions arise. Thank you for your cooperation in this matter. Sincerely, FLYNN ASSOC. P.C. Al�r d o, P.E. President AAS:nf cc: J. Cullinan prof os E d i9 /Ter na Ti v e S T o owr)er : Joseph CU1111,Ian L.000 lOn : 520 503 tor? 9Z rce �, lVor�A Andover; 177a. 4i 84 S ,fid�e • ,4 ri l /9, /9 4 /�/o 3 C a /e. 97 0 P z.z Pre c?red Ay /-r /ynn , 'JJOC . , PC'. , PO. 8,x 569 y Jry F/j/,9 t o w , Al. i� 03 8 6 5 T�/ (fU3SlOr7 (dr" OSeS Onl �n r- y- be 135ed On SI�� 'r'�sC ing �/7G` 1-vrf' rii 4 A n�Jo ver hod rd 0 Ne d nth tt?,?U r-e me n G e _ . ObseN6�10r hole to examine v f de+$(`rn;/�e. wd�e� -1-able �1�eva'��o►, Cst,;n��'�� X13 eau 1 CTJ �� 2. 745�,We- new (each,, c 4-s . _f i?r, -6, be based ' or W. Ve- U{PQ ,Sp �K�SC► _ _ J d r6 l r\ IDEs " +c 6Q Se�Ic- on SOI �� tcsu(}s system 4�a� vi—s (� !.. , C U I V a CSL cho ,crz. w f I l IaE Driveway ries u 4s �3os tori St re eZ� - 1 Z 7k 41 ) 13 70 l 1 T7WK - C.-271/2 CE�N � .M. r U vse- ~' r— a f �Y ,i/ C?G t C7 3 C7 tu, �A -52 . ice` C;� o tv IR c1 �V0 , tli�> c�ver� , y pORT#j i Otteo 6gti0 BOARD OF HEALTH " 2 120 MAIN STREET NORTH ANDOVER MASS. 01845 SACHUS� TEL. 682-6400 �S 7� June 26 ,1984 Re: Septic System Repair 520 Boston Street TO WHOM IT MAY CONCERN: On June 8 , 1984 final inspection was made of the repairs to the septic system on the above mentioned lot . Repairs consisted of two new leaching pits connected to the original septic system. Construction was done by A.D.Gibson, Jr with permission of this Board and final approval signed on June 8 ,1984. BOARD OF HEALTH Michael Gra£, Inspector r Copy of system attached FORM 4 - SYSTEM PUN PV\G RECORD N OF% .tpW BppR Commonwealth of Massachusetts Massachusetts System Pumping Record System0;7�Nr System Location i L Date of Pumping: ' �� Quantity Pumped: ��� gallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes System Pumped b%-: _ License 4: Contents transferred to: �S �• Date Inspector 1'tlott ttlntvF Ills of hl�o�a�lttl� ll� mond; Will I�yMl�lll �IIYIIFI�_..._______------._.___.._.__� .�y�IE1111•l►c�1�4,i! Septic 'I N,ik: No 1 ay�lalll 1'I�IIIIt�II Il y� �'���a� ,�'N�rp.�<er� 1•lckltea �.�. ---------- �'llttlant� Itnnsl�l�t�ll lu : !ull I moll 01111tt1M- I(al— --- a t, :. / t'nitllnt�n�►s+l��ll�of�tt����l�uselt� MagggligsetIs i ayaheord � ra, n�urYt r Systeltl Locatiucl Quantity Pumped:O gallons Yes Septic 7'auk: No U Yes -Syflgltl Plopped 4: �'�f��+4��i , License # ;lltlt3ttl$lralt0 cured IQ : (Imager, Lamm le 18,111011 0181rict -- Uttt _ Inspeclor« Ro. COMMONWEALTH OF MASSAC14USETTS (� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTME'�T OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. RIA 02108" 617-293-5500 r V WILLIAM F.WELD - TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCi �� / DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION ; Property Address:) as _� � ,�� titer T\q' dress of Owner: Date of Inspection: — \a—�` (if different) Name of Inspector: — � 1 am a DFP ppro ed system inspector.pursuant to Section 15.340 of Title 5 (3 10 CMR,15.000) Company Name: ah S Mailing Address: ( iL ek- IPA PQ, 0l%I U Telephone Number: CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete'as of the time of 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/ _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fa s 4 ,Inspector's Si nature: ��jJ �` Date: �.._ g The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEMPASSES: MP � 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indic*q below. COMMENTS: BI 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. 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 i tic tank is replaced with a conforming septic tank i m will sins di n if the existing septic p failure is imminent. The system pas pe q as approved by the Board of Health. (revised 04/2S/87) page 1 of 10 DEP on the World Wide Web: http:lrwww.magnet.state.ma.us/dep ^ Pnnte+i nn Recycled Pacer ,! COMMONurEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C' DEPARTME'�T OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM F.WELD TRUDY COXE Govemo: 3 Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM Commissioner PART A (� A CERTIFICATION N _ Property Address: S O �chg U oC� r/'1"""'r'L 4ddress of Owner: Pate of Inspection; 10— (If different) Name of Inspector: N t 1 I am a DEP.approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name; )SCk Q Mailing Address; 1 ugs— �Cf,olE f O Telephone Number: L4"'I_57— L4 t793C, • 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: _ �onditional'ly ._ Passes _ Needs Further Evaluation By the Local Approving Authority fail Inspector's Signature: , Date- The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure. criteria not evaluated are indicated below. COMMENTS: BI SYSTEM NDITIONALLY PASSES; r 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. is c� vi✓n ®rN r��v.,�? - �L' u,,�.. J V\\ P�. Indicate yes, no, or not determin (Y, N.i r ND). Describe basis of ztetermliiatia" in�I instances. If"not determin", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a CL—ificate 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 infiltrati,.,, or exfiitration, or tank failure is imminent. The system will pass inspectign if the existing septic tank is replaced with a conforming septic tank as approved by the Bc_.d of Health. (vovi*ad 04/25/97) Pogo 1 of 10 DEP on the World Wide web: http:/twww.rnagnet.stBte.ma.us/deP Printed nn Recyded raver • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5D0 �� �'. ��r /AmAo s- Owner: - L—tom-(-,%e— Date ('%e— Date of Inspection: l qj B]SYSTE.WCONDITIONALLY PASSES (continued) 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced r due to broken or obstructed pipe(s). The system will pass The system required pumping more than four times a yea inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 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 a surface water Cesspool or privy, is within 50 feet of a.bordenng vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD-OF'HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) 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 to 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 n (revised 04/25/97) Pegs 2 of 10 i i , ,A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection; D) SYSTEM FAILS: You must indicate either "Yes" or"No-as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis j 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 100 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 cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 4 (revised 04/25/97) Page 3 of 10 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5c kD C3cr_-_AF v©cA kk 4J`(xA,2� Owner: L_.V Date of Inspection: Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes 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 N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. t/ 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 used on: // The facility owner(and occupants,,if different from owner) were provided with information on the proper maintenance of __. /� Sub-Surface Disposal System. L' � Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (ssvised 04/25/97) Page 4 of 10 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: V �, Date of Inspection:: l FLOW CONDITIONS RESIDENTIAL: Design flow: ( e.p.d./bedroom for S.A.S. Number of bedrooms: Ll Number of current residents:Ll Garbage gander(yes or no): Laundry connected to sYster (yeslor no):� Seasonal use (yes or no): t�0 Water meter readings, ifa,y4ilable (last two(2)year usage(gpd): Sump Pump(yes or no):, NO Last date of occupancy: ��f COMMERCIAL/INDUSTRIAL: Type of establishment: ` Design flow: gallons/day 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 meterreadings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no) 'xS If yes,volume pumped: (S— ealloys Reason for pumping: k �5 TYPE OF S EM ptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other `3I a. S - c APPROX MATF AGE of all components, date installed (if known)and source of information: ) Sewage odors detected when arriving at tho site; (yes or no) NiJ tsovisa4 04/1S/97) Page 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address S'-­�(7 i2�a,� s4,, �JO-Ic� Owner: Date of Inspection: BUILDING SEWERi (Locate on site plan u Depth below grade: `k Material of constr c7io—n L,,dgtiron PVC other x lain) Distance from private water supply well or suction line `7 lO0 Diameter u Comments- (corylition of joints, venting, evidence of leakage, etc.) No t cxz SEPTIC TANK:.---'—� (locate on site plan) 1k s Depth below grade: �— Material of construction: �Eoncrete metal _Fiberglass ,_Polyethylene —other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: %-4 Sludge depth: '3 t Diseance from top oi,sludge to bottom of outlet tee or baffle: Scum thickness: id Distance from top of scum to top of outlet tee or baffle: 13 .� Distance from bottom of scum to bottom of outlet tee or baffle: 3 How dimensions were determined: v�fD � Comments: (recommendation for pumping, condi ' of inlet ands outl�tees or bC es depth �f�liquid level in relation to utlet i ve structural i rity, evidence of leakage etc.) v e �� Ste ' CA" V ti V\ PJB Gtnti �' f -c s CJ eZ\ 'C- GREASE TRAP:IIR®re- (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc.) (revised 04/2s/97) F&ge 6 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: in� Date of Inspection: TIGHT OR HOLDING TANK: (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 level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: • (condition of inlet tee, condition of alarm and float switches, etc.) s DISTRIBUTION BOX:— (locate OX:V(locate on site plan) Depth of liquid level above outlet invert:_ Comments: (no a if Ir�el and dist ibution i,�equal, evi ence of solids cart over evidence�eakage in or o f b �t 06 'L9 'l Ct , PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No)�E--5 Alarms in working order (Yes or No)�(Q„� Comments: (ripteconclition of pu to chamber, condition of pumps and appurtenances, etc.) Y" %J Wove e717 Q r u n (revis*d 0{/25/97) Pago 7 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C ' SYSTEM INFORMATION (continued) Property Address: j c0 12�csAvo Pa(Akh— "wx Owner: L ki�-A 4e— Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_„- (locate on site plan, if possible; excavation-not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:,_ leaching galleries, number: I leaching trenches, number,length: 4 trIusine leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments:. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) cv 1 YAC ' CESSPOOLS:.CQ'v\-e (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: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:VM00-C (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.) (revised 04/25/97) Page a of 10 i I i a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benrks locate all wells within 100' (Locate where public water supply come n r 40 AAc. Q— Q i i I n (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property.Address: Owner: Date of Inspection: l Depth to Groundwater H Feet Please indicate 11 the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the !-sigh Groundwater Elevation. (Must be completed) (revised 04/1S/97) Page 20 of 20 7 Tel: (978)475 - 4786 Fax: (978)475 - 5451 BATESON ENTERPRISES, INC. �xcavating-Water&Sewer Lines-septic Systems&Pumping Service I I 1 Argills Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: '"` Owner: Date of Inspection: 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 fiuther operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. Commonwealth of Massachusetts City/Town of RECEIVED ? j System Pumping Record DEC 17 2008 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. th fb'r.t tcffi�� �/Gt'ed, ut 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 Important: When filling out 1. System Location: Left fron , le rear, eft sid of hous . Right front, right rear, right side of house. forms on the computer, use only the tab key Address ��� - to move yourL�> t cursor-do not City/Town State Zi Code use the return P key. 2. System Owner: Name Address(if different from location) Cityrrown Stat N�7—1 0 tZip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. QuantityPumped: Datep Gallons 3. Type s yp of system: Q Cesspool(s) 0—se tic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? Yes _ No If yes, was it cleaned? Q Yes No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loc ' contents were disposed: L.S.D Lowell Waste Water lFad igna ure ofFH u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Locaatiioon: fomes the computer, use only the tab key Address to move your J a 0 cursor-do not �yfT� Ste Zip Code use the return key. 2 System Owner: v ILS Name 1�1 Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record r C✓C-��� ���� 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 of System: 6. System u ped,-By Name � -jVehicle License Number Company t 7. Location where contents we disp d: L— - 41,/Y Signature of ul Date t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of w° System Pumping Record RECEI D Form 4 APR 2,8 mi DEP has provided this form for use by local Boards of Health. Other form a used, but the information must be substantially the same as that provided here. Before si� Pflr1dv6Ai our local Board of Health to determine the form they use. The System Pumpi6blmitt d to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of hous Le �reo`f�ou e, n ht rear of house, left side of building, right rear of building, under deck City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State _ Zip Code g 7 Telephone Number 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 of System: 6. System Pump: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Locati where contents were disposed: L.S we aste W r C SignatureOf H er Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ulw 0.6 TES u irIA eY OG__. uv.. _. • E iG , ePrlc Ta►Ati 22.5 ' �H . 7Z pis r. 13o c IaN' i K vaT IP9,Zo . + + E W-00 Ord 136 121' w.. 're K :neg. L� u ES 12 014, i mol 2,a �tAm 6A4 tAL �"�• �61,0 OWES 'ff= la•o Bow-�j0�•1 �-r'��E-r k5 Du iI.OT SUBSURFACE DISPOSAL. SYSTEM LOCATED IN �tlV;N AODayG�-; Miss, AS PREPARED FOR DeUA .9 Gu e.lrI5 WeL6 DATE : J u uY SCALE: I c}p t MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • ' PLANNERS ` 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 i TEL (617) 475•3553. 313.5721 t i _ ulLi� r1 E+ TES LJHrIA V-Y G 10V 5 6%16. to"- A 6 G PE lc 9 S• 6Pf�a Ya►.�� 22.5 W,' � ,�� � 7Z 61 T W!5 ICY' (3.,c 4 DIsT *cK iool 9AV vuT IP9,Zig ar►tr�-r�2.� I ' 1 ' c *I- I oCOO b 10 13all k -reg i o Wei go 8,00, I ® �- — L e�c�� Ll u ES I r--— iD N h�2-A 0 zxptic� G VOW ti Bo�Ort �T'►Z.�E'r t SUBSURFACE DISPOSAL. SYSTEM � LOCATED IN AS PREPARED FOR DATE : .A 1,,1 LY SCALE: MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • ' PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01110 TEL (6171475-3553, 313-5721