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HomeMy WebLinkAboutMiscellaneous - 55 FULLER ROAD 4/30/2018 55 FULLER ROAD 1D/D65.0-D07&D000:0 Town of North Andover,MA August 29,2017 55 Fuller Road Property Information t th, Property 065.0-0078-0000.0 ID Location 55 FULLER ROAD Owner TABOLA,MICHAEL ' i r r h z »Y7+;.`' 'r'" r7 IN - CL a r,� �- MAP FOR REFERENCE ONLY NOT A LEGAL DOCUMENT _' ar Town of North Andover,MA makes no claims and no warranties,expressed or implied,concerning the validity or €? accuracy of the GIS data presented on this map. r r 70 ft • � r ax w t r, u:��c _. 44 u -�:.e=-�± i c(. ,, SS �3ikJJaI��, e � d✓�� f �a 1 wavy -.a va 3 q-. ha` F �� f _..'nom.- .._.�..-�\ . ,z �'Se, f °� + tea.� _ ��r" a.•��+ � F -y _ _ .>< . _ �,.� t�.e_ .� '"�r 1 �1. cS F ��4, f •^ F 1 ,71 ?t EF .� � � 1 �..rt � ._,..�a� �.�''� �t�s-�..�. •f �( _ .. � Y _ - i YS`F IN ,/♦1 - f r 3N' ,h•..u1'_ E` k 1R lift said F;-fs, ,(.q 52 44 14, x � I c "�Y g —< ^ +f f- "'+vhK,. 4,=cd_fs�✓._,+K�'F � Y �"4. a .. ����.�.�..;k'gt �. + n..� � f y s ' TOWN OF NORTH ANDOVER OCT 2 5 2001 SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (egamp e: left front of house) DATE OF PUMPING: QUANTITY 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: s NEW ENGLAND ENGINEERING SERVICES INC s March 4, 1998 North Andover Board of Health Town Hall Annex 30 School Street North Andover,MA 01845 RE: TITLE V REPORT 55 Fuller Road. Enclosed is a copy of the revised Title V report for 103 Fuller Road,North Andover,MA. The system now passes our inspection. If there are any questions please call me at my office, 686-1768. Yours truly, Bi C. Osgoo Jr.,E.I.T. President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 - ------.. .. .---- --- COM. MONXV'EALTH OF MASSAC14USETTS (r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTENT OF ENVIRO'�MENTAL PROTECTION M ONE WINTER STREET. BOSTON. hIA 02108 61:-292-5506 TRUDY CORE WILL1A%l F VELD • Scactar5 Govcmo- ARGEO PAUL CELLUCCI ev\5e DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A nn /CERTIFICATION Property Address: 55 F�1(e ve Zg, /)- .4 Address of Owner: Dale of Inspection: (-31-95 � 3 -2 -Ct9 (If different) Name of Inspector: BENJAMIN C. OSGOOD JR. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 CERTIFICATION STATEMENT ceni that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate fY Pe Y 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: LLasses Condrtronall\ Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date 3-2" Q 8 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 byyer, if applicable- and the approving authority- I INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: V I have not found any information which indicates that the systern violates any of the failure cr:te::a as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. (n/ COMMENTS: ./ r 5re iH< <P? �f �a �41 �et� OlGcc Q w 7i^ ei /7L 7Ti'a 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 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 pus inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (r•��•.d Ol/7S/f71 p•7J• 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: .s.S F.AIc/L �J`., /U. f}r.,Np.�C'1L Owner: J;r Dale of Inspection: 61 SYSTEM CONDITIONALLY 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 Healthi. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): 3 broken pipets) are replacer obstruction is removed III C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire iunher 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 ENVIRONOENT: Cesspool or pri.1•is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: i _ The system has a septic tank and soil absorption system(5.11) and the SAS is within 100 feet to a surface water supply or tributary to a suriace water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supp'v 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 irom 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 (r—i—d 04/25/771 P.9. 2of 10 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,, (� CERTIFICATION (continued) Property Address: y F✓QQ��C� Kai /V. Owner: �/l c DG(.(PJ✓►1G/1 Date of Inspection: DJ 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 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 dogged SAS or cesspool 3 � Static liquid level in the distribution boa 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 Anv portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a suriace water supply. Any portion of a cesspool or privy is within a Zone I of a public well. ) An% portion of a cesspool or privy is within 50 feet of a private water supply well Anv 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. anach copv of well water analysis for coliform bactgria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: I I 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 go 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. (r.viv.d 04/75/11) faq. 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: SS C_,jj t_ Q� � N. Owner: E, c Q u(,teJwr\.on Date of Inspection: r Check if the following have been done: You must indicate either -Yes"or'No' as to each-of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped (or 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 pan of this inspection. As built plans have been obtained and examined. Note d they ere not availab)e with N/A. _ The iacility or dwelling was inspected (or signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ The site was inspected ns of breakout.for s� _ Pe 8 ✓ _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholets were uncovered, opened. and the interior of the septic tank was inlpecied 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: _✓ _ The facility owner(and occupants, if different from owners were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex.IPlan at B.O.H. i Determined in the field epi anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J i (r.vi..d Ot/2S/fel P.V. 4 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION Property Address: SS ��l�t/' ►2►yt r /U. 19-'C 0')e2. Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: e.P.dJbedroom for S.A.S Number of bedrooms:,_ Number of current residents: N Garbage grander (yes or no?:_.4_ Laundry connected to system (yes or no):j Seasonal use (yes or no): A/ Water meter readings. if available (last two (2) year usage (gpd): .Sump Pump (yes or no):/V Last date of occupant)•:C v/rC•;-('- COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: vaIIons/dav Grease trap present: Ives or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title i system (yes or no)_ Water meter readings, if available Last date of orcupancv ( OTHER: (Describe? Last date of occupancy. GENERAL INFORMATION PUMPING CORDS a d source�iniorm�ationm� cg w5 �c System pumped as pan onyes or no) iV If yes, volume pumped: aallo�s Reason for pumping TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: T�jit/ ew• Sir1 1 5 Sewage odors detected when arriving at the site: (yes or no)Z (ravla,ad 04/2S/91) Day. 5 of 10 - - ------------------- ......................... _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: j 5 /� Owner: _ ✓t GJ f/L Date of Inspection: !`t C �(U`YV\a✓n BUILDING SEWER: (Locate on site plan) r. Depth below grade: Material of construction: ✓cast iron_40 PVC _other(explain) ' Distance from private water supply well or suction lir- Diameter �— Comments: (condition of joints, venting, evidence of leakage, etc.) �' lX -cv ws O K t A/ 1-4 0 0 SEPTIC TANK:_ (locate on site plant Depth below grade:L Material of construction: ✓concrete _metal _Fiberglas; _Polvethylene _other(explatn) if tank is metal. Inst age _ Is age confirmed by Cemitcate of Compliance _(Yes/No) Dimensions: )5-00 (rALto ./ Sludge depth: o`- < Distance from top of sludge to bottom of outlet tee or barilte: 32 Scum thickness: 0" Distance from top of scum to top of outlet tee or baiile. (91 < Distance from bottom of scum to bottom of outlet tee or baffle: _ How dimensions were determined: 5 c 14 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stru4tural integrity, evidence of leakage, etc.) 7:4, V, ) S Ne t-LJ i GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Dale 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.) (r.vi•.d 01/2S/97) P�q. C of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ss- 1/t c �L�� V, Owner: �/';c goy�d t!'✓►'�a.n Date of Inspection: TIGHT OR HOLDING TANK: i7ank must be pumped prior to,or at time, of inspection) (locate on site plan) Depth below grade: P Material of construction: _concrete _metal _Fiberglass _Polyethylene other(explain) Dimensions: Capacity: gallons Design flow• . gallon>da% Alarm level Alarm in working order_ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plani Depth of liquid level above outlet invert: Comments: (note ii level and distribution Is equal, evidence of solids/car r�o+er, evidence of leakage into or out of box, etc.) ' 13 ox /S I A A oo cX c o n r Y ri o/) SD irl e P✓,'�Pn f P �7C ca/rry o rJ t,� PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber; condition of pumps and appurtenances, etc.) (rwi—d 04/33/971 ►.y• 7 of 10 ...... ..... - »� z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM nn INFORMATION (continued) Property Address: SS fvJ16- �. f>)ncXJJGt Owner: Ery.� a a1v'man Date of Inspection: _31 [ - 4 2_yq 3 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) I(not determined to be present, explain: Type: leaching pits. number.- leaching chambers, number:_ leaching galleries, number: leaching trenches, number length: leaching fields. number, dimensions:LF`ic �- overflow cesspool, number: Alternative system: Name of Technology: Comments (note condition of soil, sips of hydraulic failure, level of ponding, condit n of vegetation, etc.) . I CESSPOOLS: _ (locate on site plan) Number and configuration Depth4op of liquid to inlet invert. Dppth.of solids layer- i Depth of scum laver: Dimensions of cesspoo!: Materials of construction: I I Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (rwi—d 04/25/57) P.q• a o[ 10 v .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,S-5 FAex— 11,0, Aj. QL),vt Owner: Date of Inspection: I -3►- 98 ; 3-Z- �f3 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) I i ' I G J Q� \AO J�4 J 25.5 Z.S1 O 4LIG(1- T v 5 3.S p�77 fav X (r.vi..d 04/75/97) P.q. 9 of 10 • ................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION (continued) Propertv Address: �-s F,Ile,< /1A Owner: 4( i'r'c a Date of Inspection: B Depth to Groundwater & Feet Please indicate all 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 irom local conditions Check vtth !oca! Buard of health __16Che6 FEMA Maps Check pumping records Check local excavators. installers Use USGS Data Describe in .our own words how you established the High Groundwater Elevation.,(Must be completed) 1� Cr!`ec1 ceco, erce—f �N��h f;�(c 3 %2D y e 140 cz e o. Z/ I blyd..✓S Wim, 7?- ILC �" lie � � •v r . • V .S•Cr-S. /J��•. �- f�Y�a o� Lds:fev,1 KGs E, l(�r4 ��� pj��`j 1�� ex1S '9vk�'o M R M APS $ K40t--eo,-,&e�:- /9"-0 yc-�o 7b Jb<1 ci�dV 'Y� -e -F-10)Jo P��^ i (r.vi..d 04/23/97) P.y. 10 or 10 i1 , t a / Doo ---- -.- -- -- - - - - - - - - � SEPTIC PROFILE � o _ TOP OF FN 142°04 INV. 135.47 �o \ T MIN.COVER 12 D- SOX INLET WNo SLOPE= a2 INV. 13G2I _ INV. !35°37 _ iHOUSE 0 TLE T ' .-----D Box OUTLET L j INV. 135-09 ( 135.25 ) END OF PIPE T O P INV° 135°97 BOT. OF BED � 13-�oQ9 ( 134°25 ) TANK INLET \ INV,. 13567 ,.� c c-� TANK OUTLET SJI!/YoTo ( f30°25) 4OTE( � D_NO T I�,DESIGN ELEV. • SCALE. VERTa 1"' 4' 0" OD HOICIZo 1=40"-0"____..__._ PL:AN AN D PROFILE c HOW 1 NG SUBSIJRFACP SE\-VE 1 SAG D P ,� - , QUy%NERo AY �- -RI ,C� ,J SQN R^_ L i i�� LU� iTiON° LOT I i ( 24 ) FULLER RD* Y DATED 10-9-81 °RF ,� BY ss AIF+RED �G / �11 ` t 0c. pig 4 ST NOTE- BENCHMARK = TOP JI= FN D-LOT 15 E LEVO 1= 57 U.SL-,So DATUM, SEE PLAN BY GEL I NAS AND AS SOCo DATEDS 3-23-91 7230►\-%' 0o SEPTIPROFILE � TOP OF FN 142°04 INV. 135247 NIN.COVEr 19" D-BOX INLET t / / � INV. 13eo21 — INV. 135037 HOUSE OUTLET j ! � - D BOX OUTLET INV. 1,35-09 ( 135.25 ) END OF PIPE OP INS 135.37 ,' ! { BOT. OF BED I \ 1.34.09 ( 134-25 ) TANK INLET L S \ INV. 135067 r ��� — TANK OUTLET � ; YOTE( L�_NO ! E DESIGN FLE'�o S�HNIaT. , 130025) } SCALE o VERTo I"' 4' O". O HORI7o 1=40'-O„ �. N�' AN D _PRS;F1[1 � 10\11;" 1 NG S�, BS :I;FAC: �1�r li`—_-- �! � D1 ' P —) t I 1\ � '1 l _— n R r""1 —1 E 0V\,NERc' J�,YSON E.,�;L i fR�� L ,' -/ T i 0 Noo LOT .11 ( 24 ) FULLER R Do OATEo 10-9-81 - B Y � � aAL. G � 1 -OWP C/ N/�J + f� �� ` �` �� 0 f < ST .F ^ NO I E oEN C;I IMARK = TOP Or FND,LOT 15 ELEVa 1 . 1 57 US.G aS. X\ DATUM, SEE PLAN BY GELINAS AND ASSOCo -p DAT EDa 3-2� i Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location l J. Date of Pumping: '— — �"'� Quantity Pumped: l (Ct/gallons L , / �.-) Septic Tank: No �� Yes Cesspool: No 1� Yes p System Pumped by: vareeoat 5'riavwed License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 000 ► i `� ? SEPTIC PIPOF I E 1 L D:l � �� TpPOFFN ~ � `2 � 142004 I, - _ INV. 135.47 �.� MIN.COVE? 12 D-BOX INLET —i ISI I N. SLOPE= Ca,? Iry Vo 13no21 INV 135037 NOUS E OTLE T I 4�— D BOX OUTLET INV. 1,35-09 ..( 1,35.25 ) �— QI END OF PIPE o O P� INV.I35o�7 ' j BOT. OF ICED TAI�IK INLET 13 )o �� ( 134025 ) 1 N Vo 135fl6 7 —4 T ANK OUTLET,LEVo S -{N002 )P,OTE(- � DENOTES SCALE ' VERT' 1, HORIZ. 1=40'-C) _ DI AND PP0ll::_llLE '5_'iH0\Ai NG SUBSURF/a._ GCA DRP�S. � , E �SEWE I RUQOVNCR � LLT L 1�/AT I o u— LOT .11 ( 24 ) FULLER R DG �. 4 DATE' 1O-_.j �( BY PR 1_5 / /1` XPi o PCD _ ! ,o ALFRED FL 5 IST NAL ;.' G ! _ _ � f NOTE -BEN C HMARK = TOP OF ENDoLOT 15 ELEVo I44a57 UStiSa/ DATUM, SEE PLAIN BY GELINAS AND ASSOCo -0 y DATED' 3-23-81 r Town of North Andover, Massachusetts Form No.3 NORTH BOARD OF HEALTH 4 ° hr �° &Z,�j r a.✓'Y /Z-19� O 1° DISPOSAL WORKS CONSTRUCTION PERMIT SSACNUSE Applicant I/vG— ©cam NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption Sewage.Disposal System as shown on the Design Approval S.S. No. ,� , CHAIRMAN,BOARD OF HEALTH Fee .. . .. D.W. o. Iv i,. YI; ;fat! Board of ;Seaith, < . 'forth Aj�� qr r . SEMC MTEM IN,sTAj..1AT1OK CCK IS SP LOT Ptt'ROVID DATE DIS rFc�(7V ID z1AT w XCAVATI ON w 01 FA_+.L i JbpdQl.lV 4♦4i• / /jIj''''''yJ r FAIL OK 1. Distance To: I a. wetlands b. Drains c. Well ' 2. Water Line Location E 3• No PPC Pipe Septic Tank----' a. _Tees -_Length & To Clean Ont Covers _ b. Cement Pipe to Tank - On Both Sides of Tank = �. Distribution Box �- a. Covers & Box - No Cra*,ka b. All Lines Flowing Equal Amounts c. No Back Flow 6. - Leach Field or Trench a. Dimensions b. Stone Depth CO Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth -- c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading 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 1 � f Fc�r,nass J SUBSURFACE DISPOSAL DESIGN CHDCK LIST LOT bq DATE DISAPPRoM DATE Reasonss _ � ay III V FAIL CS 2.5 The submitted plan must show as a minimums a) the lot to be served-area &Lmensions lot i ,abnttera -- b location and log deep observation hoes-distance c location and results pe2'coZgtion tests-distance to ties ��� calculations & calculations showirire ties e location and dimensions of g mired leaching area f existing and proposed contours reserve area g) locationareas tours - disclaimerchewck wetland thin 1001 of sewage disposal s PPS system or (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer � al (i) location any drainage easements within 1001 system or disclaimer- °f $age disposal kao�.n sources of �a�Pg Board Piles _` _ system or disclaimer �PZ,�' within 2001 of ses'age disposal , location of =7 proposed k-P-U to serve lot-100 location of dater lines on property-10v from leaching� from leaching facility- location of benchmark facility. (n) driv�eiErays . 9 garbage disposals 'no PVC to be used in construction (q) Profile of system-keva.tions of basement I distribution box inlets and outlets, distribution field piping tanks ®tDer elevations P P and maximum ground water elevation in area seg,-age dais / s) plan mist be Prepared by a Professional Posal=sYste� Professional authorized by law to �gineer' or other t' prepare such plans t 6 Septic Tanks (a) czpac t es- 50% of flow access, purging s water table; tees, depth of tees, r �b) cleanout { c) 101 from cellar %all or inground swimmiu d) 251 from subsurface drains g Pool l0.2. ✓- Distribution Boxes to.� b) ss o�pe greater 0.08 I 3 NEW ENGLAND ENGINEERING SERVICES INC j FEB 18 19,J J L February 7, 1998 . North Andover Board of Health Town Hall Annex 30 School Street North Andover, MA 01845 RE: TITLE V REPORT 55 Fuller Road. Enclosed is the Title V report for 55 Fuller Road,North Andover, MA. The system conditionally passes our inspection. If there are any questions please call me at my office, 686-1768. Yours truly, Benjamin C. Osgood Jr.,E.I.T. President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 O .. 1 V -3 ..-\ CO.MMONWTALTH OF MASSACHUSETTS Vy EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I Tr, DEPARTIMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. IJA 02109 617-293-5500 FEB I � tc3 TRUDY COXE F WELD _ tk1LU!l�! WILLI ! Sccrctur� w: w --- DAVID B.STRUHS ARGEO PAUL CELLUCCI Commissioner Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Q CERTIFICATION /� 2c� Al, 9-'.—Jq oe'e- Address of Owner: Property Address: ✓ �/L Date of Inspection: (If different) Name of Inspector: BENJAMIN C. OSGOOD JR. ' 1 am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA_01845 Telephone Number: 508-686-1768 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 in and experience in the proper funaron and and complete as of the time of inspection. The inspection was performed based on my training pe P Pe maintenance of on-site sewage disposal systems. The system: _ Passes CondrltonalK Passes _ heeds Funher Evaluation By the local Approving Authority Fails Inspector's Signature: Date: Z - Lf The System !nspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. I(the system is a shared system or has a design now of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional otfice of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the byyer, i(applicable. and the approving authority I INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: 1 have not iound any information which indicates that the system violates any of the failure cr-te"a as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated 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 NO). Describe basis of determination in all instances. If-not determined', explain why not. e iro a of The septic tank is o a �- w II r C ' as insta ed the-s iartk, whetrhe• ,.• -+nr rat i need, sty ��ra�►;� *shows ubstantial with a conforming conff orming exng cseptic tank ion or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced w as approved by the Board of Health. (Y—i—d 04/2S/971 p-9. 1 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: `js fAclt A), Owner. )-:rrIC �cc�e(t►�u/1 Dale of Inspection: t — 3 61 SYSTEM CONDITIONALLY PASSES(continuedi 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 1with approval of the Board of Health;. Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaces obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require iunher evaluation by the Board of Health in order to determine i(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 pn.-�•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 APPROPRIATES DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system I&AS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. I The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. stem The s has a septic tank and soil absorption tem and the SAS is within 50 feet of a private water supply well. _ Y P P The tem has a septic tank and it absorption tem and the SAS is less than 100 feet but 50 feet or more from a s s s p so p system om private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds that unds indicates t the well is free irom 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 (twi��d 04/75/77) Paque 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: y,- j=:.,lle,c d, A), Owner: �/1 c Ct�mGn Date of Inspection: DJ SYSTEM FAILS: You must indicate either `Yes-or-No-as to each of the following: 1 have determined that the system violates one or more of the following failure criteria as defined 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 r r 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 flo%+-. 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 Svstem, cesspool or privy is below the high groundwater elevation Am• porton of a cesspool or privy is within 100 feet of a surface water supply or tributary to a suriace water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ! An,. porton of a cesspool or privy is within 50 feet of a private water supply well. Anv 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 Nater quality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis for cohiorm bactgria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] DIRGE SYSTEM FAILS: I I You must indicate either -Yes- or"No-as to each of the following: The iollowing 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 saiety 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. (revimed 04/25/77) Page 3 of 10 i SUBSURfACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: js F�(!t'.0 Qct , N. A,.,93Qeic. Owner: c Q>cc(.1 eJwr�on Date of Inspection: I - 3 1- yg Check if the following have been done: You must indicate either `Yes"or"No"as to each-of the following: Yes No — Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or as pan 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 J — All system components. excluding the Soil Absorption System, have been located on the site. The septic tank manholets were uncovered, opened. and the interior of the septic tank was inlpected 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: — — The facility owner land occupants, if different irom ownen were provided with information on the proper maintenance of Sub-Surface Disposal System. / — Existing information. Ex.iPlan at B.O.H. t Determined in the field (if anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (I 5.302(3)(b)] i (revised 04/23/9-Y) Page 4 of 10 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION Property Address: Y_'(k l /V• -A,&,iLA Owner: -6a llPlvl�A^ Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: a.pu.dJbedroom for S.A.S Number o(bedrooms:___L Number of current residents: H Garbage grar.der(yes or no?: A Laundry connected to system ;es or no): Seasonal use tyes or no)A/ Water meter readings. if available (last two (2)year usage (gpd): .Sump Pump (yes or no): IV Last date of occupancy.Cullelf i COMMERCIAIJINDUSTRIAL: Type of establishment: Design flow: yallons/dav Grease trap present: (yes or not Industrial Waste Holding Tank present: Ives or nol_ Non-sanitary waste discharged to the Title i system ryes or not_ Water meter readings, d available last date of a-cupancy: OTHER: (Describe! Last date of occupancy. GENERAL INFORMATION PUMPING R CORDS nd source of�niormauon ✓it �� �� System um ped as part of inspection: (yes or no) Q If yes, volume pumped: t allo�s Reason for pumping TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: cc) l4 2 Sewage odors detected when arriving at the site: (yes or no)/V i (rsvissd 0{/2S/57) Paq• 5 of 20 ------------ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �J S GCjll/L J.JQ /(f tq4O o e,12- Owner: 2Owner: F/`ic Qtiketw%or/1 Dale of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Z y Material of construction: ✓ cast iron_40 PVC _other (explain) Distance from private water supply well or suction lire Diameter V 11 Comments: (condition of joints, venting, evidence of leakage, etc.) A'12 a SEPTIC TANK:_ (locate on site plana N Depth below grade: Material of construction: [concrete _metal _Fiberglass _Polyethylene _other(explam) If tank is metal, list age_ is age confirmed by Cendicate of Compliance _(Yes/No) , Dimensions: 5-1 o G-n Ito I Sludge depth- ysl ,r Distance from top of sludge to bottom of outlet tee or bafflie:ZS } Scum thickness: /" — Distance from top of scum to top of outlet tee or banle:,4/,4_ Distance from bottom of scum to bonom of outlet tee or baifle:A/A How dimensions were determined: Mewore S i�rld, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stru4tural integrity, evidence of leakage, etc.) OF C/ ^' D e, rle< e• r I ' GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _,Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom 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.) (r-i-d 04/75i17) pay. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /� SYSTEMINFORMATION (continued) Property Address: S j s FJ 11{R j a, /V, v�- Owner: Fl-;C- Ucrm�.� 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 f!o%.• gaUonJda. Alarm level Alarm in working order — Yes: _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) ) DISTRIBUTION BOX:Ar (locate on site plan) Depth of liquid level above outlet inven: [� Comments: (note if level and distribution is equal. evidence of solids/ca/rre+er, evidence of leakage into or out of box, ettc.) 15 OX /S /Aq dc7 cX c o n rY "3.6/) �Dir1 eP✓i Ao re o!' re en! 2J O�J Ge: I I ! PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r—i.ed 04/25/97) P.V. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM nn INFORMATION (continued) Property Address: Owner: 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: leaching trenches, numbei,length: j 1 leaching fields, number, dimensions:Lfie 9U0 overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, conditygn of vegetation, etc.) A D� Sv cfCM dna Lis dao f CESSPOOLS: _ (locate on site plan) Number and configuration Depth-top of liquid to inlet invert: DRpth•of solids layer: Depth of scum laver: Dimensions of cesspoo!: Materials of constiuction: I I Indication of groundwater: inflow(cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r•via.d 04/25/97) p.9. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �� ��1��� ��� /(�- �h�v✓� Owner: Dale of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) To 57(ye t ? l��vE c 1 I �o Dc o f� 3�•3 33„5 I (revimed 04/75/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properiv Address: /1� V. R,,,�O✓K Owner: Date of Inspection: �rr'c B A4(Cl✓17 G,-7 �- �31 - qg Depth to Groundwater & Feet Please indicate all 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 : 1 Check %vrth !oval"Buard of health _v_'_ Checi FEMA naps Check pumping records Check local excavators, installers Use USGS Data Describe in vour own .words how you established the High Groundwater Elevation.)(Must be completed) )� erred ct Gece•LfF;er c rS 3` %Zt y ` j3 , -/t n s'j.S�e Wk e� ��u �•����s�y S'K Lt w 4L,-0 Ya c (r•vi•.d 04/25/97) P•q. 10 or 10 Address-SS,_r—o f�t� Title of File page of Date File Open: Date ale closed: Doc. Document/Action Title Date of Refer to other Purpose of Document/Action and notes. action Document/ document/ filum• Action De artment Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department Commonwealth of Massachusetts RECEIVED City/Town of NOV 2 5 2008 a` System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT SV bye 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 Location: Left fr left re left si of ho se. - ht front, right rear, right side of house. forms on the computer,use only the tab key Address �� to move your cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State � ^�^Zip Code Telephone Number B. Pumping Record _ 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Cesspool(s) - e tic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? If yes, was it cleaned? p Yes No 5. Condition ^of System: ln� 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location here contents were disposed: L.S.D Lowell Waste Water igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF f U cv SYSTEM PUMPING RECORD rOCRE—CEIVED DATE: T 1 4 2005 TOWN OF 'JR1"1H1 ANDOVER SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) VLoosv-, DATE OF PUMPING: QUANTITY PUMPED : -�GALLONS CESSPOOL: NO L---Y—ES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Commonwealth of Massachusetts ' 4 D City/Town of NOV 2012 System Pumping Record Form 4TOWN 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. A. Facility Information 1. System Location: Left/Right front of hous , Le ' Rig rear of housed Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date 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: \ i 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Z.Signe Lowell Waste Water Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1