Loading...
HomeMy WebLinkAboutMiscellaneous - 54 VEST WAY 4/30/2018 (2)Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record S77p 1.E 2014 Form 4 TOWN f)h i`lthRt`M ANDOVER �IrAt-Thi p�I�ARTMENT DEP has provided this form for use -by local Boards of Health. Other" orm ay 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 LocationOn Right front of house, Left / Rig r of hou Left/ right side of house, Left / Right side of buil eft / Right front of building, Left / Right rear of building, Under deck Address City/Town 2. System Owner. Name Address (if different from location) Cityirown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): \-� State Tp Code State � ,�Zig,Code Telephone Number i a r Data 2• Quantity Pumped:Gallons —� Cesspool(s) eptic Tank ❑Tight Tank 4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No. 5. System Pumped By: AK Neil. Bateson Name Bateson Entemrises Inc Company 7. I - F5821 Vehicle License Number contents were disposed: Lowell Waste Water &A. ulelf I Date t5form4.doe- 06/03 System Pumping Recons • Page 1 of 1 41 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 V 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 hous , A Rig �rear Left/ right side of house, LeftRight side of building, Left / Right front of blyttd nng, Left/uildin , Under deck 9 Address ( City/Town 'v ` Sate `�' � Trp Code 2. System Owner. Name / Address (if different from location) CitylTown F State"°'1 Telephone Number �y B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No: ' S. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson EnterDrises Inc Company F5821 Vehicle License NOV 'I 9 2013 I OF NORTH ANDOVER 1LTH DEPARTMENT 7. Locaoiamwfiempontents, were disposed: C LLowell Waste Water Sign a Haul Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Ir —] Commonwealth of Massachusetts RECOVED City/Town of System Pumping Record OCT 26 2012 Form 4 TOWN OF NORTH ANDOVER w s 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. A. Facility Information 1. System Location: Left/ Right front of hous Rightlj a , Left / right side of house, Left/ Right side of building, Left / Right front of buil Ing, Left / Right rear of building, Under deck Address City/Town v v�— �j State 2. System Owner. Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ sle�6s-�- Zip Code Stat�� . ip ode Telephone Number 10 -- ( I`7 - u) - Date 2. Quantity Pumped: Cesspool(s) D -S p is Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 0 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location wJxwe contents were disposed: G.L,�S. _ Lowell Waste Water Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number cv L---? ` f cz'�— Date t5form4.doc• 06/03 System Pumping Record . Page 1 of 1 K'*\ Commonwealth of Massachusetts' City/Town of LHEALLTHMi'-P%A ANDOVER System Pumping Record ENT Form 4 M 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. Syste cation: Left front of house, right front of house, left side of house, right side of hou Left ,Fr of hous P, right rear of house, left side of building, right rear of building, under deck. 2. City/Town State Zip Code System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Conditio of System: ic)�- V� 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Loc n where contents were disposed: G.L.S. Signature State Zip Code Telephone Number — 2. Quantity Pumped: at—eptic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date Com-- t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 �LN Commonwealth of Massachusetts City/Town of . RECEIVED System Pumping Record y` Form 4 NOV 1 01009 DEP has provided this form for use by local Boards of Health. Other for TvtwR information must be, substantially the same as that provided here. Befo e u i your local Board of Health tQ determine the form they use. The System Pumping Recor mus ed to the local Board of Health of outer approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, dear of house,'15ight rear of,house. Deft rear of building. Right rear of building. Address / Cityrrown 2 System Owner Name Address (if different from location) CitylTown B. Pumping Record State Zip Code State Zip Code r,�: ��1 " Telephone Number 1. Date of Pumping I ) _ ' � � �2-antity Pumped Date 3. Type of system: ElCesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: , 6. System Pumped By: Neil Bateson k5oa Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location wlier4p contents were disposed: G.L.S Lowell Waste Water Signature of Hauler Date t5form4.doc- 06!03 System Pumping Record . Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 5 9 V`e - ' Cw,- .. ' �R ri At\'Dd`JER I 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. OCT 2 3 2008 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return kkey. A. Facility Information 1. System Location: Left frorl , left "rear, ft sid f house: Right front, right rear, right side of house. Address � - City/Town 2. System Owner: Name Address (if different from location) City/Town Zip Code State Zi Code 3 17 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 0 Cesspool(s) _ eptic Tank Fj Tight Tank Ej Other (describe): 4. Effluent Tee Filter present? 0 Yes _ No If yes, was it cleaned? 0 Yes 0 No 5. Condition of System: 6.. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: .LS.D Lowell Waste Water igna ure of H 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. The System Pumping Record must be submitted to the ocal Board of Health or other approving authority. . A. Facility Information Important: When fining out 1. System Location: forms on the computer, use only the tab key Address A to move your cursor - do not�—C1. use the:return Cityfrown tate Zip Code .key. 2. System Owner Name ICI . Address (if different from:location) Cityfl"own . Stawl ZiD _ Telephone Number TOWN OF A) AvM SYSTEM PUMPIN RECO DATE: -'z -0q SYSTEM OWNER & ADDRESS ,YVEM LOCATION (example: left front of house) RECEIVED 3 0 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DATE OF PUMPING: QUANTITY PUMPED: r - 5 o �_ GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES 7 NATURE OF SERVICE: ROUTINE ,EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIl-4) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D.-Z Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: —22-0 Ist � 6-� q 4t%l Qc( ) .TIO (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED_ GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES SOAP. 0 CDS a NATURE OF SERVICE: LTVA ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: s 0 2 T 2006 FULL TO COVER BAFFLES IN PLACE=- LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: ce�: , l • < e,, Commonwealth of Massachusetts -Massachusetts System Pumping Record System Owner ,t ( "Js—� Date of Pumping: Cesspool: No Yes [I System Pumped by: V4&j dW saavww System Location Quantity Pumped: `gallons Septic Tank: No [ License # Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: Yes [fig a Commonwealth of Massachusetts U , Massachusetts System Pumping Record System Owner Date of Pumping: 6 /)5"-- / Cesspool: No [ 41 Yes Ll System Location qy 9tiairiity Pumped: I'd -z' gallons Septic Tank: No C J - Yes 14" System Pumped by: Fetwort Sre&,Zfy dej License # Contents transferrred to : Greater_ Lawrence Sanitary District Date: _ Inspector: TOWN OF NORTHANDOVER/ BOARD OF HEALTH JUN 2 2 1999 i' i. P] W Z = O z° c; _LU a O LL �y J W 0 .O ! � W Z � LL 0 Z �o V c ++ W Z0. �� Q rl kALn JUl QLLJ�L W Q OC O LL Z a b4 p p Q Q N U L Q ce N t Z m p o 0 3 V "' o -j c c 3 to n a t o p Ln Z y — N 0.40 r U to CL a) NMol. ,�;,► `r Q N N U a N U- APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERII�IIT DATE: �o — 5 — D ° CTj=, iT D, 'STALLER'S LICE`+ Em LOCATION: q U,.s LICENSED D`1ST� � �`7� � � �e S d .c/ SIGNATURE: TELEPHONE, CHECK ONE: REPAIR: C,,� NEW CONSTRUCTION: Lt-;— —Ii�"x �) 0 IF NEW CONSTUCTION, PLEASE ATTACH FOLiYDATION AS -BUILT. 575.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes No Yes No Floor Plans? Yes No Approval Date:4 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at S_�41 Pro relative to the application of �,44e sd� , dated 6 —OF.5-- 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. c; 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. Under e -,d Licensed Septic Installer J �U Date: c�s �d i L 2 7 _" COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPABTIMM OF ENVIRON MAL PROTECTION 4 ONE WINTER STREET, BOSTON MA 02108 (617) 2924500 TRUDY CO%E .9 ARGEO PAUL CELLUCCI DAVID B. STBUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM 11SPECiWIiI FORM PART A CERTIFICATION Property Address: 54 Vest Way, North Andover Name of Owner. Richard Selbst Address of Owner: 54 Vest Way, North Andover, Me. 01845 Date of Inspection: 6/3/2000 Name of Inspector:. Neil J. Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title S (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: Passes _X Conditionally Passes Needs Further Evaluation By the Local Approving Authority nacopy Inspector's Signature:C�� Date: 6/3/2000 The System Inspector shis inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ---=--tet NOTES AND COMMENTS --r ��VER/ r . revised 912/9$ Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 6/3/2000 INSPECTION SUMMARY: Check A, 8, C, or D. A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 390 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. D -Box needs replaced. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. _N_ 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 exfiitration, 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. _N, Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed prpe(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 _N_ 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 912/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Vest Way, North Andover Owner. Selbst Date of Inspection: 6/3/2000 C. iFURTHER 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 sal absorption system and the SAS is within 50 feet of a private water supply wail. The system has a septic tank and sal 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 912198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 613/2000 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 facTi ty 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 coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E.ILARGE 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 9IV98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 61312000 Check if the following have been done: You must indicate either "Yes" or"Nd" 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 ff 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 infomaation. 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 912198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 613/2000 FLOW CONDITIONS RESIDENTIAL: Design flow _150 _ .g.p.d./bedroom. Number of bedrooms (design): -4 _ Number of bedrooms (actual-4— Total actual4_Total DESIGN flow _600 Number of current residents: _2_ 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. N/A Sunrp Pump (yes or no): _No Fast date sof occupancy _!Cu COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis sof 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 6/17/1999, owner System pumped as part of inspection: (yes or no)_ No_ If yes, volume pumped: _gallons Reason for pumping: 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, N 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: 16 years old. 113/1984. As built plan. Sewage odors detected when arriving at the site: (yes or no)_No_ renAS9d 912198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 61312000 BUILDING SEWER: X (Locate on site plan) Depth below grade: 28" Material of construction: _X cast iron _X 40 PVC _ other (explain) Distance from private water supply well or suction line: Diameter :4" Comments: 4" Cast iron thru wall. 3" PVC in house. SEPTIC TANK:X (locate on site plan) Depth below grade: 16" 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: 3" Distance from top of sludge to bottom of outlet tee or baffle: 24" 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: Inlet tee ok. Outlet tee corroded on top. Depth of liquid at outlet invert. No evidence of leakage. 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 912/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 61312000 TIGHT OR HOLDING TANK None (Tank roust 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) Dim, ensigns: 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. Evidence of solid carryover. Evidence of d -box leaking, has corrosion holes in same. Needs replaced. 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 912198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)) Property Address: 64 Vest Way, North Andover Owner: Selbst Date of Inspection: 6/3/2000 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:1 field 25' x 42' 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 Qocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 61312000 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 canes into house) Septic Tank Water Meter House J Garage Deck L'' 1 1 2 3 1 F42' revised 912/98 Page 10 of 11 Box Driveway A to 1 13'8" Ato2= 14'8" Ato3=17' A to D -Box = 30'9" Bto 1 = 20'8" Bto2=18' Bto3=15'.9" B to D -Box = 26'4" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 6/312000 ARCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE (EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 4 Feet Please indicate all the methods used to determine Kigh 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: 54 Vest Way, North Andover Owner: Selbst Date of Inspection: 6/3/2000 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. c Neil J. Bateson Bateson Enterprises, Inc. :—V "a—V 1 tti.fk. `E'i„e.\,J 1 —r—r Y C_,_l 1. V Yr% 1 j DATE : {-3-84 S-84 a v ��- SrY..E 1-40' FLYNN J`iS,50CN P C, 0riV � P / O,Vl,! .!!lAAA\\\ I//—i1 �l�s�^/./y ^/�I865 � 47- �,V, -7�4-�� -W ;�--- FLININ, -,? _ --s--� --�-w a ',. t .'4 � ..«.• r �h 'R,,, i ` 3,.+'+ ./r .s, K.. ¢ wf 3. ,c.'_4 tt,iJt'.'t „�Y ` ° �• «'�'r b ..t :y "' s .� �pr• k 1 ~ � a� •'` "rr �� � � ,t S. .r rs. -x^.;Y �°� r!�. ''l '^1,n, � a'd .r,4 - .Y�;. a�, c}.' -+`i';'.. ,r;'•�y •'' a. t , a ' tl t��k,u�� �, his• �� x�' jr w •.' . {_ ZvL , t.af# p f+' • " 6 let t ! 534?. 2 t-flT . f ° r s AI�t� r ol Ak t �{/�+�. �fn �* �a(�'�i��r �,�/�(�'.(.� p �+�.1.■�/-y/� '. ,: a •�,� �` �i- i NOT s- V .J'"��NJry}1✓l.s+?�CN •'['tt'�VL-�i K�.r1i�i7K�4.R.1, ""ANDMAOSATtlReS6B5Etl ON COWT645 IN.FIELC). - I CEATI FY THAT- I IE 4�'! i T M 4'uh 5INS iyiq ,LEU �C ". 4�— Q1�aTAt�tC3~` � WE "PLAN SHOWING"' "� RAS Bi L i V �A�` = 1 PC t 00CATONtOT44 � Ar INION � � OA, � 4"-3- 4 REV 1-5-84. � 1'40, r 141.0.4.'--"` j # t15E t 1 i i T ..137«2 (AS, UMtD } BYE + F' SF �w INLET 1370. J E TAN NL 1i €PTI ,ANN OU3 LE 13053 z• ii'H ix INLET 13&02 SOCP 0 -BOX OU i.l_T 135.92 {� [QFIELD 135„6 l t,J� of Healt,", Anc�verIH&see BF.PTIC SZSTEEi 9' INSTAS.LATICR CHECK LIST LOT'` min nemr4-4.0ISAPPRO ED AVATIC�1 OK � a; t r t . �r/lt .. - No ea Bans t pc i© r4N1G 1. Distance Tot�193 5/�'^� %��0�Vl/ a. Wetlands—e74 � .vwoo /90 b. Drains f�f ✓v vJS c.. Well 2. Water Line Location 3. No PPC Pipe j 4. Septic Tank ..a. _Tess -_Length & o Clea Out Covers. b. Cement Pipe to Tank on Both Sides of Tank---,/ 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Fkpual Amounts C. No Back Flow 6. Leach Field or Trench 8. No Garbage Disposal 9. Final Grading inspection 10. Barricading Covered System /,/ a. Dimensions b. Stone Depth c. Capped ids d. Clean Double Washed Stonel Lea/�h . a. b. Stone c. d.e. o Pit -Both Sides Clean Double 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e.' Water Table Washed Stone 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e.' Water Table ,-v aro of Health Nart}: 'Mover SUBSURFACE DISPOSAL IIFM M CHECK TMST LOT f-44- \JEnE DI SAPPROM DAA APPROM D Provided: Reasons: i Title Q FALZ CE .. The submitted plan must show as a minm„ im: Reg 2.5 the lot to be served -area dimensions lot ,abutters I blocation and log deep observation holes -distance to ties location and results percolation tests -distance to ties ,c ✓ d design calculations & calculations ahoy ng r®gnired. leaching area I (e /location and dimensions of system -including reserve area I existing and proposed contours g) location any wt areas within .100' of se -wage disposal systor disclaimer -check wetlands mapping i surface and subsurface drains Within 100' of se -rage disposal system or disclaimer mer () location any drzina.ge easenent-s i.thin 100' of se age disposal. %oorsystem or disclaimer -P a-rming Board files kno= sources of .6ater supply 'within 200' of se -go di. spo,sal e _ system or disclP.iner �cati-on�f-sny-praposed- �,-e11 to serve lot-lOJ' from 1ea_ching faces', (m location of water lines on property -10' from leach g face -location of benchmark drive,,.,-ays sals /8 garbage beu ed in construction q) profile of system -elevations of basement, plumb, pipe, septic tan}:, distribution box inlets and outlets; distribution field piping and �tl;er elevations { �}'ma�-i m ground vater elevation in area se- .. a disp sal system �(s) plan nest be prepared by a Professional Ra&-ineer or other professional authorized by lax to prepare such plans Reg 6 Septic Tanks «� (a) capacities -150%• of flog, meter table, tees, depth of tees, access, Pur -Ping (gib) cleanout w kc) 10' from cellar Imll or in.,gr ound --ng pool /(d) 25' from subsurfacce drains Reg 10.2 I I Distribution Foxes �(a s ope greater than 0.08 Reg 10.5 ,f" .-,_ absurface esign check List FAIL I M Page 2 Leaching Pits Mac hing pits are preferred where the installation is possible - alculations of leaching area-mdnirmm 540 eq ft spacing csurface drainage 2% D.,cover material splash pad f e at elbow g) no beads in pipe from d -box to pipe Leaching Fields a) no greater than 20 minutes/inch b) area -minim= 900,�flt c) constructio f field d) surface ge 2 % e) 20 � m cellar va11, or inground s i ruing pool L eaching Trcnches.---� a) calcu5.aon-'Teaching area -min 500 aq ft b) spacing ft min 6 ft with reserve betvven C) I ons d) co traction e) stone f) surface drainage 2% / Dounii?1 Slope a) slope -y7x- =to be s`io--i) b) y/x x 150 = (to be shown) fams a) b) ,id -by power SOIL PROFILE & PERCOLATION TEST DATA \ North Andover, Mass. Street No '�i "► Uj Lot No �- Loc/Subdiv. Pland Owner Investigator Observer SOIL PROFILE DATES l.!Elev 2.Elev 3.Elev 4.Elev o 4'*—z o n Benchmark Elevation l 1 2 3 1 2 `Z: V7 2 3.� .2 3 4 4 5 5 6 3 ' �*Q­ 6 7 M6ms.3st 3" drop- 7 8 Ydns.2nd " Drop 8 9 Percolation 9 10 . 10 - DATES Location Datum PERCOT,,AATION TESTS &fZ-0iSV3 &i17-0( Pit Number- 1 2 3 �+ Start Saturation `Z: V7 Soak -Minutes .2 ar Test--Time. Drop of 3" -Time Drop of 6" -Time 3 ' �*Q­ M6ms.3st 3" drop- Ydns.2nd " Drop Percolation iii \Isc=;—% ,-01�-y leo Boar,, -I of Health N,rs;th Andover,,lTass V, APPROVED DATE Provided: TitYe V Reg 2.5 3 1 I iii s Reg 6 �(a fib) (d) Reg 10.2 Reg 10.1 SUBSURFACE DISPOSAL DESIM CHECK LIST DISAPPROVED DATE Reasons: LOT #e/14�' D submitted plan must show as a M nimnm: the lot to be served-area,dimensions lot #,abutters location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations show -Ing required leaching area location and dimensions of system -including reserve area existing and proposed contours location any vat areas Athin 100' of sewage disposal system or disclaimer -check wetlands mapping surface and subsurface drains within 100' of sewage disposal system or disclaimer _ location any drainage easements vi.thin 100, of sewage disposal system or disclaimer -Planning Board files knom sources of water supply within 2001 of sewage disposal system or disclaimer location of any proposed well to serve lot -1001 from leaching facility location of water lines on property -101 from leaching facility location of benchmark driveways garbage disposals no PVC to be used in construction profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations -maximum ground water elevation in area sewage disposal system plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks capacity -150% of flow, water table, tees, depth of tees, access, pumping cleanout 101 from cellar val1 or inground sing pool - 251 from subsurface drains Distribution Boxes slope greater than 0.08 Sum Subsuffac Reg 11.2 11.4 11.10 11.11 Reg 15.1 15.4 15.8 3.7 Reg 14.1 F: 14.3 t 14.4 14.6 14.10 Reg 9.1 9.6 as_dpCb, ec FAIL I OK Pag _2 --- - -- Leaching Pits - / Leaching pits are preferred Where the installation is possible /calculations of leaching area -minimum 500 eq ft b) spacing surface drainage 2% At, over material I x2 IAN splash pad f tee at elbow g) no bends in pipe from d -box to pipe LeachLng Fii ds a) no greater 20 minutes/inch b) area- 900 sq ft c construe on of field d) surface e 2 % e) 202 fro cellar Wall or inground swimming pool Leaching enches -- a) ci .c a ns o ea Bing area -min 500 eq ft b- ft c�; spacingmin 6 ft with reserve between dimensi s d) cons tr tion e stone f surface drainage 2% Downhill Slime a) 'slope x = o be shown) b) y/x % 150 = (to be shown) a) Idt-by b) power BOARD OF HEALTH DESIGN APPROVAL Septic Tank Lot # 44 STREET ���� Permit # Proposed Construction �$�iZl-� �ut-j0 kNC., Approx Building Size --7�ox4,,o Garage /Under Attached None Min elevation of top of slab Min elevation of top of foundation �(� • l� Height of.foundation wall -7 Footing in fill yes V/ no Further Comments