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Miscellaneous - 56 GRAY STREET 4/30/2018
n - --1 56 GRAY STREET 210/107.B-0059-0000.0 i I : Commonwealth of Massachusetts RECEIVED City/Town of . System Pumping-Record JUN 0 8 2015 Form 4 TOWN OF NORTH ANDOVER '"� w 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 Recons must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Locatio &ga, /Rig front of house, ft/Right rear of house, Left/right side of house, Left ILeft/Right side of on o Wilding, Left/Right rear of building, Under deck Address `K____ City/rown State Zip Code 2. System Owner. Name* Address(if different from location) City/Town Stat p Zip Code Telephone Number r a � • i B. Pumping Record r 6; 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 ❑ Na 5. Condition of stem: stj � V 6.. System Pumped By. Neil.Bateson F5821 Name Vehicle Uoense Number Bateson Enterprises Inc Company 7. Loca' here contents were disposed: S'. Lowell Waste Water r Sig Haul Date t5form4.doo•06/03 System Pumping Record•Page 1 of 1 pORTM pEt'to-to $61 `yy O?q teui C01 ft cHus'e�� PUBLIC HEALTH DEPARTMENT fommunity Development Division %f YFRII(FICAT� O CO%(PLrINCE As of: April 18, 2010 This is to certify that the individua(su6surface d4osal system received a SA2TSFACTORTIMPEMONof the: Insta&tion o a new f 17--tic Tan and' �Lhstn$utzon Box x foran On-Site Sewage V sposa[System By. ToddBateson At: 56 Oaj Street Kap-10Z B; Parcel-59 North Ammer, WA 01845 The Issuance o this certificate shaff not be construed as a guarantee that the system T f functions actorify. S an T Sazvy r, SRVs/ T46&9feaCth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 6roc, ST GD I Z 2Oclr5 old aTIzST ------------------ ►^ew,arTc��,�e, t� .. v wd� - )e ra,rclitf 1C4wM lcokS IPGTcl"L?- 5oMe (�c+,lp 6GUe Spo,3 . l T s per►��►tel�� s��le�'- --v FIc ��� Se-�1� sc�STcw, clt�ot,gl� nDT G w revl-d� G ver til ow r v,l . T cc.V7 hd t SScA:f, G" Gppro\.r, I �GY ►rS dol, YtGTr awv)er- vrd V)pt �SSJ� �e �rv� YEPvV'i` <f ker- D©esv,` T lov� lr k,-- wrvcln C�- (ccisT- COMMONWEALTH OF MASSACHUSETTS - DEPARTMENT OF PURL?C HEALTH DIVISION OF TUBERCULOSIS CONTROL 600 WT:.',hINGTON STREET, ROOM 360 - BOSTON 02111 _Questionnaire on Status of TWherculosis Patient NAME: Please record change of address here: Address: Date of City: Birth: Please check beside appropriate words: 1. This patient is is not under my care. If yes, please give date of last-visit 19 2. Date and results of most recent sputum: a. Date : 19 Positive Negative Pending b. By smear Culture Other C. Laboratory performing test: 3. Date of last x-ray: 19 Progression Unchanged Regression 4. Present Diagnosis: (Please complete both columns) . ( ) Primary ( ) Active ( ) Minimal ( ) Active Impr. Mos. ( ) Moderately Adv. ( ) Quiescent (Cavitary) Mos. ( ) Far Adv. ( ) Quiescent (Non Cay.) Mos. ( ) Extra Pulmonary ( ) Inactive (Cavitary) Mos. ( ) Inactive (Non Cay.) Mos. ( ) Undetermined (Specify) 5. Drugs Administered: Yes: Date Started: 19 No: DOSAGE SPECIFY DOSAGE: INH PAS STREP MYAMBUTOL PZA Other s Signed: M.D. PH-TG-21-10/71 Date : NORTH 4 � OFFIQ!-:S OF: �� Town Of 120 Main Street APPEALSNorth Andover, NORTH ANDOVER Massachusetts 01845 BUILDING ;,''° ;Ib- CONSERVATIOP4 °" DIVISION OF (617)6854775 HEALTH', PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR I June 19 1987 re- 56 Gray Street Lot 2 To whom it may concern, This office has no record of complaints about the Septic System at this address . Sincerly SanitarianW- d'6 Health I, mglgc M John Sagedelli Lot 2, Grey St. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Lot 2, Gray St. . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 1000 _gal, in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 1.80 lineal {0M%K9[) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE JUN 2 7 1963 i Sature f Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE2 7 19R 1 r S-igiature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Y )JAW ' JP Signature o Inspecting Offic r Percolation Test 6 min. Soil: Clay-Gravel Garbage Grinder 4 June 20, 1963 Miss I1;Iar7 Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requestFd in order to determine the suitability of the soil for the subsurface disposal of sewage on the rroposed Gray Street (Lot -2) building site of J. J. Segadelli . The land in general is high . The subsoil in the ai.•ea was of gravel-clay content and a 6-minute p e r colst on test was conducted. It is reconmended that a 11000 gallon concrete septic tank be in- stalled together v�ith 180 lineal feet of drain pipe. Very truly yours, William J. iscoll r�JD:hd 16; � BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. /�t cz�av r Nva'` n r t ry 1 20 10 00 GAL.CoNC,TgCJ Divr, tow. 1. NAME 7'-r- �� /i/ vt C DATE f {� 2. ADDRESS 0�� � f.0 Ali Ss LOT NO. TEL. CSC.' J-C1Gfo' 3. NO. OF BEDROOMS DEN YES NO A--- ^ 4. GARBAGE GRINDER YES NO �^ 5. SHOW DIMENSIONS OF HOUSE2.51- 6. .51-6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 7' 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM �' oa r- 10. 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. A/0 y 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE /D NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. North Andover Board of Assessors Public Access Page 1 of 2 NORTH North Andover Board of Assessors Ot tt��c ��ti0 F e T MATCHING PARCELS ,SS/1CHUSet Click on a column title to sort data by that column Click seal To Return 41 items found,displayingall items.l Fiscal Year Parcel ID St.No. Street Owner Name 2011 210/107.D-0136-0000.0 0 GRAY STREET LONE STAR REALTY TRUST,C/O STELLA Search for Parcels 2011 210/107.D-0050-0000.0 0 GRAY STREET RULLO,FRANK J,BARBARA RULLO 2011 210/107.D-0032-0000.0 0 GRAY STREET TOWN OF ANDOVER,C/O Search for Sales CONSERVATION COMMISSION 2011 210/107.D-0011-0000.0 0 GRAY STREET MASSACHUSETTS LAND CONSERVATION TRUST, - 2011 210/107.D-0011-0000 A 0 GRAY STREET NORTH ANDOVER IMPROVEMENT SOCIETY, 2011 210/107.D-00 13-0000.0 0 GRAY STREET BARNSIDE REALTY CORPORATION,C/O WILLIS 2011 210/107.D-0019-0000.0 0 GRAY STREET MASSACHUSETTS LAND, CONSERVATION TRUST 2011 210/107.B-0078-0000.0 0 GRAY STREET RULLO,FRANK J,BARBARA M RULLO 2011 210/107.B-0050-0000.0 1 GRAY STREET RULLO,MICHAEL, 2011 210/107.B-0051-0000.0 17 GRAY STREET READE,CHERYL A,JOHN A READE 2011 210/107.13-0053-0000.0 30 GRAY STREET CUSHING,JOSEPH B,LOIS B CUSHING 2011 210/107.13-0052-0000.0 31 GRAY STREET CRONIN-JENKINS,SUSAN, 2011 210/107.B-0154-0000.0 45 GRAY STREET FENG,DAVID Y,LAURA J ANTONUCCI 2011 210/107.13-0059-0000.0 56 GRAY STREET MCDONOUGH,LUCY ANNE,SCOTT C BRILEY 2011 210/107.B-0054-0000.0 72 GRAY STREET ADICONIS,ROBERT J,MARIE A ADICONIS 2011 210/107.D-0055-0000.0 79 GRAY STREET HALBACH,ERIC E,JR,KATHLEEN K HALBACH 2011 210/107.D-0030-0000.0 89 GRAY STREET GORDON,DIANA, 2011 210/107.D-0121-0000.0 90 GRAY STREET BRANDT,CYNTHIA A.,BARTUS,FRANK 2011 210/107.D-0029-0000.0 99 GRAY STREET ROSENBERGER,MICHAEL A,MARY T ROSENBERGER 2011 210/107.D-0026-0000.0 107 GRAY STREET HART,CHARLES, 2011 210/107.D-0120-0000.0 120 GRAY STREET DEMERS,ERIC&MONICA, 2011 210/107.D-0056-0000.0 125 GRAY STREET ROBBAT,PAUL,LINDA L ROBBAT 2011 210/107.D-0119-0000.0 140 GRAY STREET METSCH,DAVID S.&SCHLOSS,RENEE, 2011 210/107.D-0101-0000.0 162 GRAY STREET STELLA,MARILYN A, 2011 210/107.D-0132-0000.0 168 GRAY STREET COLLART,ERIK,BROUNS,KARINE 2011 210/107.D-0012-0000.0 169 GRAY STREET MFT REALTY TRUST,MURPHY,FRANCIS &ELLEN 2011 210/107.D-0131-0000.0 1741_15 GRAY STREET ROBINSON,LEONARD B,HAHN,KAREN A 2011 210/107.D-0052-0000.0 180 GRAY STREET STELLA,BARBARA A, 2011 210/107.D-0130-0000.0 190 GRAY STREET FINNEGAN,KEVIN,LINGLEY,CYNTHIA 2011 210/107.D-0110-0000.0 193 GRAY STREET TWADELLE,SCOTT,KELLEE TWADELLE http://csc-ma.us/PROPAPP/newSearch.do;j sessionid=D685DC3 762AO4EB4A80EDB92699... 4/8/2011 North Andover Board of Assessors Public Access Page 2 of 2 2011 210/107.D-0123-0000.0L21 GRAY STREET MISHIN,AUDREY V.,MISHIN,GALINA V. 2011 210/107.D-0111-0000.0GRAY STREET MCKNIGHT,HELEN M, 2011 210/107.D-0129-0000.0GRAY STREET WEBSTER,DAVID,WEBSTER,DIANE 2011 210/107.D-0112-0000.0 217 GRAY STREET MILLER,PAUL E,LILLIAN B MILLER 2011 210/107.D-0113-0000.0 229 GRAY STREET HOLSTEN,GLENN A,HOLSTEN,KERRY A 2011 210/107.D-0128-0000.0 230 GRAY STREET HAN,TONG,C/O CYNTHIA SHENGQI LN 2011 210/107.D-0122-0000.0 236 GRAY STREET SOUSA,MERYL, 2011 210/107.D-0127-0000.0 240 GRAY STREET KWASS,WALTER,C/O DANIEL J. PROVOST 2011 210/107.D-0126-0000.0 252 GRAY STREET PRATT,ROBERT A.,O-MELIA,AMY 2011 210/107.D-0125-0000.0 266 GRAY STREET KANG,JING ZUAN&XIE,XUEMEI, 2011 210/107.D-0124-0000.0 1 280 GRAY STREET SIMPSON,JAMES&DAWN, 41 items found,displaying all items.1 http://csc-ma.us/PROPAPP/newSearch.do,j sessionid=D685DC3762AO4EB4A80EDB92699... 4/8/2011 Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner& Address: Scott Briley R VED 56 Gray Street North Andover, Ma 01845 6AR 2 2 �li u l l Location of system: Front TOWN HEALTH NORTH DEPARTMENT R Date of Pumping: March 10, 2011 Type of system: Septic Gallons Pumped: 1500 gallons System pumped by: Service Pumping& Drain Co., Inc. S Hallberg Park North Reading,Ma License#: BHP-2011-0413,0412,0411,0410,0409,0408 Contents transferred to: Greater Lawrence Sanitary District Date: March 10, 2011 Pumping Technician: PK This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes 56 6r�s�- -t W0.SW�9 w�aU� r "2 p v4- cel S "Zi-, lei- ���1e ate Ie �` easy 1 Ca(� w `��1oa7oa Firstly,I seat tour fakes dot t ,:,—as indicated in your let you aid not receives Secondly,I dropped offthe samples to the lab yesterday sampler,accordingly I beheve the"chain of custody"ha miring and did not get a reply until today.I materially re Lmtly,I am greatly coacemed by the events that have t< meet next week.My concern is not centered on the stony Sincerely, Joseph Pelich SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 5 a i (/ f / J � �7e r revised 9/2/98 Page 10 of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI Governor DAVID B. STRUHS � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 5(A-G r� 'S"t• U•.,AvLd vii,r,)' A Name of Owner YY1 i C4C&j i mb If Date of Irrspectiort: 3 13I ID (I Address of Owner: «rrl Name of hspectw:(Pleas.Print) �,--�Oil rX VT, ��„�CIL 1 am a DEPoved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: S C Mairg Address: UOV Tdq*w w Number: L 1 70— 1, 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 ti of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site wage disposal systems. The system: Passes _ Conditionally Passes Needs F her Evaluation the Local Approving Authority Fails L InspacWr's Sgnrture: Date: The System Inspectors�11/nt it a copy of thi inspection eport to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. e system is a ared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to thpropriate reg al office of the Department of Environmental Protection. The original should be sent to the system owner and.copies s the buyer,i applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 ' Page Iof11 f ~� nrinl�d on Rn 1-4 n,,,,,. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) property Address: 5L.araq Si, N. t�in'd4 L7Lr� h9 8(Til 5 Owner: N"c"' e-i k- �1l L Data of bspection: � e- INSPECTION SUMMARY: Docko B, C, of D: A. SYSTEM PASSES: _„-Z— I have not found any information which indicates that any of the failure conditions described in 31.0 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. 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 yesi no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. P Y The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe($) 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 levelled or replaced The system required pumping more than four times a year due to broken or obstructed pips(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(a)are replaced obstruction is removed *Note: THE TITLE 5 INSPECTION IS NOT A GUARANTEE/WARRANTY OF THE FUTURE FUNCTION OF THE SEPTIC SYSTEM. revised 9/2/98 Page 2of11 I . 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 54 Gl7raq �at'. N: IRAQ Uu, W4 0(SNIG Owrw M clla.ei ki ynbl Dao of Inspection: 3 1:3 too 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. i) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING W 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. 21 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 tone 1 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 fT revised 9/2/98 Page 3ortt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addreas: t, (3C(_a.0 N• Ar c2oi9u, rn A- O 1 8 u5 Owner: )It - a e-i Ll iln l e Date of Inspection: 313 0 D. SYSTEM FALLS: You must indicate either"Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 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 LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 51, Cx ra',w 3+, �A, -R n d-o 0,e-r, M H D 1 s K 5 Oww: M i Ch a e,l ki mb 1"e Dae of Inspection: 3 js310 0 Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Ye 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,Teceiving•trormal 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 NIA. V _ 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. _ 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 based on: IA _ Existing information. For example,Plan at B.O.H. Z _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) Z _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance.of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (5OwnProperq Address: 5 La�il �p , 71 Va 0 J-f-r, YYI F3 Q Iz L(5- Owner: er: Def of Inspection: 313�o FLOW CONDITIONS RESIDENTIAL: Design flow: �g.p.d./bedroom. Number of bedr oms(de ign)• Number of bedroo (actual): ' Total DESIGN flow �es"gyps Number of current reel ants: , ;lAKl C3/V-7 !!! Garbage grinder(yes or no): /1� Laundry(separate system) lyes or6zV; If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):,&0 Water motor readings,if available(last two year's usage(gpd): �11Q 0f44�,dp Sump Pump(yes or no):4•© Last date of occupancy:a�o— , COMMERCIAL/INDUSTRIAL: .Type of establishment: V411`�//,�, Design flow: oad (Bated on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 6 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) '.ast date of occupancy: GENERAL INFOR TION PUMPING RECORDS and source of information: 6-�7 - o - q 1987 too S ed s yem p umped ti pirt of inspection:(yes or o) If yes,volume pumped: gallons Reason for pumping: TYPE 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) 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: l��i0/ 4•� K�(1Q, Sewage odors detected when arriving at the site:lyes or no) revised 9/2/98 Page 6of11 ' Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION lcontinued) �-- Property Address: (e eras,/�rt, r1d d 04-(, MA b t S Li5 Owner: m i ch c,e.I (C i Ytth 1 t: Daft of Inspection: 3131 oa BUILDING SEWER: (Locate on site plan) , y Depth below grade: Material of construction:_Jvt/ast iron_,40 PVC_other(explain) Distance from Privet@ water supply well or suction line � Diameter,,1_ Comments:(condition of joints,venting, evidence of leakage,etc AO SEPTIC TANK: (locate.on site plan) . Depth below grader Material of construction:j,/concrete_metal,_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions:-4 g4r k Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:~ Scum thickness: ;e Distance from top of scu o to�of ortlet�as or baffle: Distance from bottom of scuff to Votto`m of outlet tee or baffle: How dimensions were determined:7A- &P T Comments: (recommendation for pumpin ,condi ion of inlet and outlet tees or baffles depth of liquid level in relation to outlet invert,struc ral integrity, evidence of leakage,etc.) ���,� +V� GREASETRAP (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 9/2/98 Page 7oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icortinued) "hoperty Address: 5L Grr6Lw Owner. I'll i dlac I IL;m►1 Date of Irtspecoon: 313 t 00 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:T_gallons/day Alarm present 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 plan) lepth of liquid level above outlet invert:_ OQ "� ISO-k- Comments: (note if level and distribution is equal, evidence solids carryov r,evidence of leakage into or out of box, etc.) 2- wi ✓ [ r_ O IFS L � ca— PUMP CHAMBER:�i(� (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page sof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 2 SYSTEM INFORMATION Icontinued) �-. Property Address: 6 le-�=c mq . VL 400tf, YV l fl 0 119({t Owns: )" ichcte_l k_imble__ Date of Inspection: 13 L v O. SOIL ABSORPTION SYSTEM(SAS) (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: J � 1 ; leaching fields,number,dimensions �SXH C7 �i5 `� � overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, c.L O vza1chALF vh CESSPOOLS: (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.) (I�ocat 4plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) revised 9/2/98 Page 9of11 J i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) naWW Address: 15 Ca j Ljr, h'1 A 015�t 5 Owner. m i cAle-e-k ��rnb► Date at Nupwdon: 313�o SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) A - C revised 9/2/98 Page 10 of 11 J 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "'ProportyAddress: '5(0 Owner: YYIi Clla �mbl L Dato of : MRCS 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 01 Estimated Depth to Groundwater 35#eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) ZDotormined from local conditions(,4/SD T Chocked 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) {� '� �� alz.F -t-�a•�'- > d 4A '�k*AW� ,il l /Mamh eP I 0 V RaW , PRAS 10" "44, �. c . 6.Q2'� �.e.p�.. �e�Qc�►-� �1 ounce �to►�ic�P, r��b rO b Lzaxk� j �I revised 9/2/98 Page 11 of 11 Pow . .... �............... .... ...._ . 1 .. 1V. Ir � Office ■ ■,' �.�.,✓! 1 ,.+.�-« )_ •rQ „ 1..1+4n� �r ,if..: !1 ir.�rlf f'1 �.,•�t ..�.; �" ?�' !,�, S�c�cT : ti ; 'a -��T '�v •v'�IJ ;:r",dsµ, �c a�µ•}� 7 I ti;�' 3 ,a a `� .� y,.a � �� a•: `�� a _,,� ti� �' �•, � � �..J '„� .R y .;An `a �I� ..' ^� M�• '.J •]. �.y2P'J x+.71`{ WC'f "Id",T tom, p.. r. #� '•:= I {: 4 i LU LLJ LU tr�`IM� N 111 ,61F., " 411 N 3• .4 CZ C Lfl 1'• yy��,, il• I••' V7 •9: I� l�) IW til .V•I _ Li' j� << uj rA Cr.0:1 cc r— a •� :( CN Go C:I �. tr I CT ca W u O I u.) CIS O. •' h- I ULO Ln II rA UI • F � I rN ;k , a) >r IL„ W 1 } © W i 01 E i f 1 C SMl1i1604A/CS/U05/L007 TD41N OF NORTH ANDOVER DATE: 82/18/00 TERMIMRL NO: 000 CONSUMER METER F/M TIME: 09:40:30 - Y Acct: 61-2237000-0 KIMBLE, MICHAEL & ANGELA 56 CRAY ST Meter No: 001 -Rev Mtr/II: N 000 Book: 9 Page: 22370.00000 Meter Flo: 0 -[1] C Connector: ] Digits: 3] Dim Cd: Aj Multiplier: ] Arb u: ] Manf Cd: ] Units: Pipe Size: ] Len: T e: Req: 00/00/0080 Inst: 00/00/0000 Cnct: 00/00/©m Disc: 00100/©090 Cd: 0] C Urk Cd: . - ] Ht Code: ] Met Lac: ] In/Out: ] - Notes: 5/8 TRI ] Serial II; 0016419154 1 Bon: Cur: 827 C Preu: 819 E 2nd Prey: 800 E [2] From: 02/24/1999 To: 06/01/1999 Cur2: Prev2: Next: 00/00/0000 Cns Cr: Mth Bill: 03 User: ] -------------------------- Consumption Infarmation ----------------------------- --- First 12 Billing Honths ------[3] ------ Last 12 Billing Months -------[4] z O6/1999 8C 12/1997 26CI 06/1996 - 14C 12/1994 11R 03/1999 19E 69/1997 26CI 03/1996 19C 09/1994 19E 12/1098 19E 06/1997 15CI 12/1995 15A 86/1994 ISE d 09/1998 15C 03/1997 18C] 09/1995 ISE 03/1994 33A c 06/1998 19E 12/1996 17A] 06/1995 17C 12/1993 29A 03/1998 23A 09/1996 18C] 03/1995 13C 09/1993 Z Total:First 12 223 Last 12. Total: b <ESC> to Enter Ne :Meter Number <M>odify, <D>elets or <N>ext 0 0 N ♦ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF EN mNMENTAL PROTFd,'nm ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 TRUDY COXE ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FOW PART A CERT WATWN Property Address:56 Gray Street,North Andover Name of Owner:Michael Kimble Address of Owner:56 Gray Street,North Andover,MA. 01845 Date of Inspection:2/7/2000 Name of Inspector:Neil J.Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name:Bateson Enterprises Inc. Mailing Address:111 Argilla Road Andover,MA 01810 Telephone Number:(978)475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: Passes _X Conditionally Passes rther Evaluation By the Local Approving Authority Inspector's Signature: 9ATZ�� Date:217/2000 The System Inspectors91the4systemis his inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspectiohared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS FEB 18 revised 9/2/98 Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:56 Gray Street,North Andover Owner:Kimble Date of Inspection:2/7/2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Porch Washing House machine line Garage to wetlands Water Meter A B A to 1 =20'9" Ato2=227' A to 3=24'2" Drive A to D-box =277" 1 Way B to 1 =27' 2 Bto2=26'6" Bto3 =27' 3 B to D-box=28' D-box 40' revised 9/2/98 Page 10 of 11 • N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:56 Gray Street,North Andover Owner:Kimble Date of inspection:217/2000 INSPECTION SUMMARY: Check A, B, C,or D.- A. :A.SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: B.SYSTEM CONDITIONALLY PASSES: �X One or move system components as described in the'Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Washer Machine discharges to wetland on side of house. Indicate yes,no,or not determined(Y,N,or NO).Describe basis of determination in all instances.If"not determined",explain why not. _No_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _No Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced No 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:56 Gray Street,North Andover Owner:Kimble Date of Inspection:2/7/2000 C.FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and sal 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 sal 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 well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance (approximation not valid). 3) OTHER revised 912198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:56 Gray Street,North Andover Owner.Kimble Date of Inspection:217/2000 D.SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 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.LARGE SYSTEM FAILS- You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area @ IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 912198 Page 4 of 11 ' r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:56 Gray Street,North Andover Owner:Kimble Date of Inspection:217/2000 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No _X Pumping information was provided by the owner,occupant,or Board of Health. _X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _N/A As built plans have been obtained and examined.Note if they are not available with NIA. _X The facility or dwelling was inspected for signs of sewage back-up. _X_ The system does not receive non-sanitary or industrial waste flow.The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _X Existing information.For example,Plan at B.O.H. Pervious Title 5 Inspection paperwork. _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 � I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 56 Gray Street,North Andover Owner:Kimble Date of Inspection:217/2000 FLOW CONDITIONS RESIDENTIAL: Design flow::_N/A_.g.p.d./bedroom. Number of bedrooms(design):_N/A_ Number of bedrooms(actual_3_ Total DESIGN flow_N/A Number of current residents:_4 Garbage grinder(yes or no):—No Laundry(separate system)(yes or no):–Yes–If yes,separate inspection required Laundry system inspected(yes or no)Yes.Washing macine discharges to open pipe into wetlands.On side of house. Seasonal use(yes or no):_No_ Water meter readings June 97'to June 99=17,000' x 7.5=127,500gallons/730 days=175 gals/day Sump Pump(yes or no):_No Last date of occupancy:_Current_ COMM ERCIALII NDUSTRIAL: Type of establishment: Design flow: gpd(Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informationTumped 10/98 System pumped as part of inspection:(yes or no)_Yes_ If yes,volume pumped:_1000__gallons Reason for pumping:Inspect tank,baffle&tee. TYPE OF SYSTEM _X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information:House built in 1966,34 years old. Owner Sewage odors detected when arriving at the site:(yes or no)- No-revised 9/2/98 Page 6 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:56 Gray Street,North Andover Owner:Kimble Date of Inspection:2/7/2000 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _X cast iron_ 40 PVC _ other(explain) Distance from private water supply well or suction line: Diameter:4" Comments:4"cast iron thru wall to septic tank. SEPTIC TANK:X (locate on site plan) Depth below grade:6" Material of construction:_X concrete_metal_Fiberglass_Polyethylene_other(explain) If tank is metal,list age_Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions:Tx 5'x 4' x7.5=1000 gallons. Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:25" Scum thickness:8" 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: 13" How dimensions were determined:Subtract scum&sludge depths to tee length. Comments:Pumped septic tank.Inlet baffle ok.Outlet tee was replaced with plastic tee with gas baffle.Depth of liquid at outlet invert.Snaked outlet pipe to D- Box,pipe ok. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:56 Gray Street,North Andover Owner:Kimble Date of Inspection:2/7/2000 TIGHT OR HOLDING TANK:_None (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction: concrete,metal_Fiberglass Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow:_gallons/day Alarm present Alarm level: Alarm in working order:Yes_No Date of previous pumping: Comments: DISTRIBUTION BOX.:_X_ (locate on site plan) Depth of liquid level above outlet invert:o Comments:ID-box level&distribution not equal.Found outlet pipes into d-box to much.Cut pipes,distribution now equal.Evidence of carryover.Pumped D-box to clean.No evidence of leakage. PUMP CHAMBER:_None,gravity system_ (locate on site plan) Pumps in working order.(Yes or No) Alarms in working order(Yes or No) Comments: Revised 912198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)) Property Address:56 Gray Street,North Andover Owner.Kimble Date of Inspection:2/712000 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:3 trenches 40'long. leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments:Soil ok.Vegetation ok.No sign of ponding to surface.Camera leach lines,no standing water in pipes. CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: PRIVY:None (locate on site plan) Materials of construction: 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:56 Gray Street,North Andover Owner.Kimble Date of Inspection:217/2000 NRCS Report name Sal 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 >6 Feet Please indicate all the methods used to determine High Groundwater Elevation: 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 x Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) Essex County sal map,shhet#36 Canton soil water.6'deep. revised 9/2/98 Page 11 of 11 t Tel: (978) 475-4786 Fax: (978) 475-5451 BATE S ON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 56 Gray Street, North Andover Owner: Kimble Date of Inspection: 2/7/2000 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. Ir kBato el J Bateson Enterprises, Inc. NORT/ ` 467 2 3 t 9 Town of North Andover � '- HEALTH DEPARTMENT ,SSAC14US�t CHECK#: JX DATE: D LOCATION: •.�i./ H/O NAME: r CONTRACTOR NAME: -% Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: y ❑ Septic-Soil Testing /$ ❑ Septic-Design Approval $ ® Septic Disposal Works Construction(DWC) $4� 06 ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ fid' Uther. (Indicate) $� Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Map-Block-Lot Commonwealth of Massachusetts �� ys< •.d 107.B0059 a Board of Health P } ermit No North Andover BHP-2010-0485 ----------------------- �i•b'."a `�y FEE �Ss�cwvsEi $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateso - - - - --- --- --- ---------------------- to(Repair-TANK&D-BOX ONLY)an Individual Sewage Disposal System. at No -56-GRAY-STREET as shown on the application for Disposal Works Construction Permit No. BHP-2010-048 Dated January 29,2010 ---- -TE-CO-P--Y - Issued On:Jan-29-2010 Board of Health woR,k , Commonwealth of Massachusetts Map-Block-Lot °, "O ,��•tioot 107.B0059 ----------------------- Board of Health o - a Permit No • '► BHP-2010-0485 « North Andover ----------------------- • P.I. FEE �ss��►+us�� F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bat-eson ---- ------------------------------------------------------------------------------------------------ to(Repair)an Individual Sewage Disposal System. at No 56 GRAY STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2010-048 Dated January 29,2010 -------------------------------------------- Issued On:Jan-29-2010 - 1 7- goail'of;fPe'a"A at y¢RTk �ti Commonwealth of Massachusetts Map-Block-Lot a $. 107.60059 p Board of Health ----------------------- North Andover ;�►''�••;�°-�" CERTIFICATE OF COMPLIANCE ,SSAtwU`+t� THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair) by ....Todd----------Bateson----------------------------------------------------------------------------------------------------------------------------------- Installer at No 56 GRAY STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2010-048 Dated January_29,2010 ----------------------- ----------- ----- Printed On:Jan-29-2010 Board of Health Application for Septic Disposal Svstem oAConstruction Permit - TOWN OF TODAYS DATE 49 250A0—Full Repair �•- -�; ORTH ANDOVER, MA 01845 $220.00-Component �SSAC Important: Application is hereby made for a permit to: When filling out R Construct a new on-site sewage disposal system* forms on the only b y �7e air or replace an existing on-site sewage disposal system* to move your air orreplace an existing system component—what? 1 AWA, z cursor-do not use the return key. A. Facility lnforrnation �V Address or Lot# l „ City/Town .4 2.-*TYPE OF SEPTIC SYSTEM*: ❑Pump Gravity(choose one) JAN 1 1 2010 ***If pump system,attach copy of electrical permit to application** TOWN Oh NORTH ANnAVER Conventional System(pipe and stone system) HEALTH DEPARTMENT ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner Information Name � , S(, C" , Address(if different from above) Cityfrown State Zip Code 97,' 3.o 0/,q, / Telephone Number 3. Installer Information Name / Name of Company`' Address Ali ®-i Z:i'l o Cityrrown State ZipCode 9,"7r ?/4 --d-1,,3 Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address Cityfrown State Zip Code Telephone Number(Best#to Read►) Application for Disposal System Construction Penal Page 1 of 2 ' "OoT;�ti Application for'Septic Disposal System /o 3r'�` • ' �°�- ` pConstruction Permit - TOWN OF TODAY'S DATE $250.00-Full Repair .,,�.. �� ORTH ANDOVER, MA 01845 "SSk< $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 52�7 4 — — / —1 l-/v Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: v 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump System? If so,Attach copv ofElectrical Permit Yes No 4. Foundation As-Built?(new construction ronly). Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 1 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: ,-:519 G 1�-n Y X54 - (Address of septic system) For plans by Relative to the application of �d Qr� 1-1se (En ' eer (Installer's name) And dated n ate . Dated .-.1 —�� o ay s ate With revisions dated (Las(revised date) I understand the following obligations for management of this project: 1. As the installer, I am.obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall.be applicable. 3.` As the installer,I am required to have the necessary.work completed prior,to the applicable inspections as indicated below. I understand that rebuestinv an inspection without completion of the items in accordance with Title 5 and the Board of Health Regularions inav result in a$50.00 fine being levied against me and/or my eompanE. a. Bottom ofBed—Generally, this is the first(V)inspection unless there is a retaining wall,which should be done:first. The installer must request the inspection but does not have to be present. b. Final:Construction.Inspection—Engineer must first.do their:inspection for elevations,ties, etc. As-built of verbal OK(or e-mail to:healthdept@townofnorthaindover com).from the engineer must be submitted to the Board of Health,after which installer.calls for an inspection time. Installer must be present for this inspection. With a 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'0 grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work(other than rirrle excavation)and I am required to complete the installation of the system identified in.the attached application for installation. further .understand that work done by others unlicensed to installse tics stems in North Andover can constitute reasons for denial of the system andlor revocation or suspension of my lice_ ns_e to operate in the Town of North Andover significant fines to all persons involved are also possible 5.. 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 ofHealth staffor consultant. d. Installation_of tank,D-Box,pipes, stone, vent,pump chamber,retaining wall and other components. 6. As the installer, I understand that I am.solel res onsible for the installation of the s stem as er the approved plans No instructions by the hoineowner general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date _ ) (Name 7.,QSd�cJ w acne� e TOWN OF NORTH ANDOVER Permit Number NORTH ANDOVER,MASSACHUSETTS 01845 ZtORT�, Date Issued Of'J"60- �,, x Expiration Date n sg�ci+ust Jackie's Law — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applican gAj �� ��N Phone Cell Street Address -`-114- RJ 97Y City/ own MA ZIP /y , V-C f� t/ d �� d Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of Property�!^, ( � Phone Cell Street Address .S'[p t-Ay s� 97f - 3oY — 9�U� City/Town MA ZIP A/p. ✓J-F`— Other Contact Permit Fee Received No Yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(eg;pipes/cable lines etc..)Please 'use revers�e/side if additional space is needed. d�[ Insurance Certificate#: ,'t, 54)j- . . Name and Contact Information of Insurer: J P,o • L3oX js pU-. A-1 114. r ys Policy Expiration Date: :s— /—/0 Dig Safe#: ®0�0 0300 9/S Name of Competent Person(as defined by 520 CMR 7,02): Massachusetts Hoisting License# License Grade: 4 AExpiration Date: BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.c. $2A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORT{ DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH) LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLIC SIGNATURE DATE EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWN 'S SIGNATURE DIFFERENT) DATE:-------------- 2 I P a g e Summary of Excavation and Trench Safety Regulation(5 20 CMR 14.00 et seg.) This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass.gov/dps Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division of Occupational Safety, drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction-related purpose on public or private land or rights-of-way. All municipalities must establish a local permitting authority for the purpose of issuing permits for trenches within their municipality, Trenches on land owned or controlled by a public(state)agency requires a permit to be issued by that public agency unless otherwise designated. In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators,.whether public or private,take specific precautions to protect the general public andprevert unauthorised access.to unattended trenches. Accordingly,unattended trenches must be covered, barricaded or backfilled. Covers must be road plates at least'/,"thick or equivalent;barricades must be fences at least 6'high with no openings greater than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who will be present during times when the trench will be unattended by the excavator. The regulations further provide that local permitting authorities,the Department of Public Safety, or the Division of Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown until re-inspected and authorized to reopen provided, however,the excavators shall have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of Public Safety for identified violations, Summary of 1926 CFR Subpart P-OSHA Excavation Standard This is a worker protection standard,and is designed to protect employees who are working inside a trench. This summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational purposes only and does not constitute an official interpretation by OSHA of their regulations,and may not include all aspects of the standard. For further information or a full copy of the standard go to www.osha aov. Trench Definition per the OSHA standard: o An excavation made below the surface of the grotmd,narrow in relation to its length. o In general,the depth is greater than the width;but the width of the trench is not greater than fifteen feet. • Protective Systems to Prevent soil wall collapse are always required in trenches deeper than 5',and are also required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection options include: o Shoring. Shoring must be used inaccordance equipment manufacwith the OSHA,Excavation standard appendices,the turer's tabulated data,or designed by aregistered professional engineer. o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment manufacturer's tabulated data,or a registered professional engineer. o Sloping or.Benching. In Type C soils(what's most typically encountered)the excavation must extend horizontally 1 %feet for eve' foot of trench.rench and%foot for depth on both sides, 1 foot for Type B soils, Type A soils. o A registered professional engineer must design protective systems for all excavations greater than 20'in depth. continued 9 . 0� `1 • Ladders must be used in trenches deeper than 4'. o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed lateral travel for every worker in the trench. o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the ladder. • Inspections of every trench worksite are required: o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm. o Inspections must be conducted by the competent person(see below). • Competent Person(s)is: o Capable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the trench,and other working conditions which may pose a hazard to workers,and o utho 'zed by management to take necessary corrective action to eliminate the hazards. Employees must be removedfrom hazardous areas until the hazard has been corrected. • Underground Utilities must be: o Identified prior to opening the excavation(e.g.,contact Dig Safe). o Located by safe and acceptable means while excavating. o Protected,supported,or removed once exposed. • Spoils must be kept back a minimum of 2'from the edge of the trench. • Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment and heavy material as far back from the edge of the trench as possible. • Stability of Adjacent Structures: o Where the stability of adjacent structures is endangered by creation of the trench,they must be underpinned,braced;or otherwise supported. o Sidewalks,pavements,etc.shall not be undermined unless a support system or other method of protection is provided. • Protection from water accumulation hazards: o It is not allowable-for employees to work in trenches with accumulated water. If water control such as pumping is used to prevent water accumulation,this must be monitored by the competent person. o If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used to prevent this water from entering the excavation. • Additional Requirements: o For mobile equipment operated near the edge of the trench,a warning system such as barricades or stop logs must be used. o Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6). o Employees must wear high-visibility clothing in traffic work zones. o Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous atmosphere exists. If a hazardous atmosphere is found to exist(e'g-,Oz<19.5%or>23.5%,20% LEL,specific chemical hazard),adequate protections shall be taken such as ventilation of the space. o Walkways are required where employees must cross over the trench. Walkways with must be provided for crossing over trenches>6'deep, y h guardrails o Employees must be protected from loose rock or soil through protections such as scaling or protective barricades. 4 f COMMONS AND REQUY MENTS PURSUANT TO GI.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the,application,the applicant understands and agrees to comply with the following: i. No trench maybe excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said-requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); ii. Trenches may pose a sig$nnii5cant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws,an excaSator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safe�hazard that may exist as a result of leaving said open trench unattended: Excavators should consul regulations promulgated by the Department of Public Safety in order to familiarizethemselves wih the recognized saft hazards associated with excavations and open s and the procedures equired or recommended by said department in order to make every rea ionable effort to.eliminate aid safety.hazards which may'include covering, barricading or otherwisrprotecting open trenches i�om accidental entry. Persons engaging in JIM in MY trenWng operations shall familiarize themselves.with the federal safety standards promulgated y the Occupational Safety 1 and Health Administration on excavations:29 CFR 1926.650 et.seq.,entitle Subpart P"Excavations".' iv. Excavators engaging in my trenching operation who.utilize hoisting or other mechanical equipment subject to chapter 346 i iall only employ individuals licensed to operate said equipment by the Department of PubHo Siety pursuant to said ehaptdr and this permit must be presented to said licensed operator before any ex vation is commenced; V. By applying for,accept'ig.and signing this permit,thelicant hereby y a ttests to the following:(1)that they have read and uncle stands the regniations pron4ulgated by the Department of Public Safety with regard to,construction re ated-excavations and trench safety.; (2)that he has read and understands the no federal safety standards inulgated by the Occupational Safety and Health Administration on excavations:29 CMR 1 26.650 et.seq,,entitled Subpart P"Excavations++as well as any other excavation requirements established by this munici ali •and 3 that h ' p tY, ( ) a is aware of and has,with regard to the proposed nIch excavation on privateroperty of pproposed excavation of a city or town Public way that forms th 'basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be post dlin plain view on the;site¢f the trench. For additional information please visit the Department of Publ�c Sfety's website at www masuwv w 3(Page..._.•,._._•,•..•.._........_,. ._._.._....__..._._.___._------�._1.�.;.._....__.._..._.__.___—_._..._..----_..__._._.__ I i � FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *************-****************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT---, �G! /6.,ei PHONE LOCATION: Assessors Map Number d PARCEL SUBDIVISION LOT (S) STREET ST. NUMBER OFFICIAL USE ONLY RE IIAENDATION O _FYOWN AGENTS: CONSERVATION ADMINIST TOR L-AE REJECTED 0 COMMENTS 5") tS ct'u aoea —con f;(/v7 - D 6e pLtifs,�� ]C/ r 10i ,V TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD IN CT -HEALTH DATE APPROVED DATE REJECTED T I ECTO150<H DATE APPROVED 7 o DATE REJECTED J COMMENTS —.:::�x_,-4 " >. /,C) /b / PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm __ CERTIFICATION ;�PLS�1�Mq� r TOWN OF NORTH ANDOVER poRTH q Office of COMMUNITY DEVELOPMENT AND SERVICES !0- A HEALTH DEPARTMENT , 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 „ES`h Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: rp MAP: LOT: INSTALLER- 0 V02 y �� DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: b a 0 I� INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS []Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK Bottom of tank hole has 6" stone base - t L&&" vcaW Weep hole plugged 1500 gallon tank has been installed H-10 loading Monolithic construction []� Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) Inlet tee installed, centered under access port [� Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 NORrk TOWN OF NORTH ANDOVER of q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT A. VM0A 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 fSSACHUs�� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER NoerH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT A 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 is CHus���� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476-FAX D-BOX Installed on stable stone base P, U%1W [ v� Inlet tee (if pumped or >0.08'/foot) [� Hydraulic cement around inlet & outlets []� Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER F NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ~ So A 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01.845 3"1845 Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation—Feb 2006 Page 4 of 6 i TOWN OF NORTH ANDOVERQ µoRTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER MASSACHUSETTS 01845 '9Ss 9 ACHUS Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 El Private drinking well 75 100z SD ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. in Watershed 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains(intercept g.w.) 25 50 ❑ Drains(Other)Foundation 10(5) 20(10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Wastewater System Documentation—Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER 4µortrH Office of COMMUNITY DEVELOPMENT AND SERVICES o °it�.o ° 0 HEALTH DEPARTMENT A 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER MASSACHUSETTS 01845 �qs � SwCHUSE Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Wastewater System Documentation—Feb 2006 Page 6 of 6 Commonwealth of Massachusetts RECEIVE _ City/Town of a System Pumping Record MAR g 201Twih Form 4 TOWN OF NORTH AN DEP has provided this form for use by local Boards of Health. Other for HE N information must be substantially the same as that provided here. Before using this form, ch 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 side of house, Right side of house,,,ft front off, Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address 9 City/Town State Zip Code 2. System Owner: B�^\ C044- Name Address(if different from location) Cityrrown State Zip Code 3OLf— Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [-S ptic 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 Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L .D Lowell Waste Water 7V 67-1� S — 10 g to a of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 12 Lq SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) �c0` � � � s DATE OF PUMPING: A 1 9- 6 l QUANTITY PUMPED l GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ' ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION x FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) 1� SYSTEM PUMPED BY: ��cy ec S �� U�c,� 4 Tin COMMENTS:' c` U CONTENTS TRANSFER TO: i e� f Conmno wealtl of Massachusetts I'v av—.&41�assachusctts 1 System Pumping Record II System Owner System Location uA�le Date of Pumping: �� ?� -� Quairtity Pumped: ZJ gallons Cesspool: No � Yes Septic Tank: No Yes System Pumped by: Siredoet Srerevlaa License# Contents transferrred to : Greater Lawrence Sanitary District llate: _ _ Inspector- F' � � �'�� • `-�assci�usel s a f J' • f a ao d e steal -uCeliUn � POlo Af)►nn!pttlg: 'e s�oclI: Nu Yes LI Sep ie Tank: No L J Yes NY01e111 Pumped 4" lPf�Ooxo Licellse # ,, .� �!a1il��lla iranaticrrt'�e� Its ' �AAlar L,A r� ���A111t9C>I��trlel ,. lnspeclov o m . . .. ., - y♦.. 1. ' ' t It :� /moi C '` ` SSp SUB6URFACE` SEWAGE 'DI.ISPO _ SYST .: 1�i8PEC:'�ION ;:FORM D ;f' 1 . . Address of ?property` 3-�. 6-RRY -, r. �.. �vc�2 ,� ✓��.Ao'v�. r2 Mme, J " �; .. :n.. i. ..:•r: . .a .. _ .: . - :+ owner.._s.,.name. 4. a. S y�,. ��xN „� c�2C�Flnt Date ko'f Inspectionll" ' - 1�°1 T,F .. �a - =Y' ' A' sy E41 TST , C x S- 4/ t ` Check if tk e follbo41:h have been- do :e a ;� f -a T .i,. r. G rta i Pu =�t ori : as :``. e��.a..�_ �,f" t � � .��er ..,oc a t ` and ' Bcai°t I. o�. m �nforma a. w z h cu :�. �..._� �:, R Mgr ., , ,. ,;. �� , F -�',: ,, A�,tH:eal�th;� S, , � .�. ' t a: jj1 -,.t t't ,_ _ None Qf the system, components y,a . been' �7t. np(, f_, at least two w ti s n:y a s ' and `�t2'e��sy,.stem°has-`been receivt="I E�ormal � -6 rates durin11' g that „ fi+soh a y r s1. 3 % per�.odzti Lange`svalumes `of water t� a=`e not �� introduced :into: the 1. I { ,.:system-,reeentA.l� or," as,,.part'"of �a ,,{.5 inspec.�w®n.» ; r 1 . Z,i 1. u As bu��, 1.t plans, have been obta Frau grid a reed. eNote f ,they, are1. ',�f�b available with:. N/A, a „ _ The fac%ility a> dwey l ing was �� 9=� :ted f } s'a gns' o1. f sewage oack .u1� :' .5 y (, / i v i 4 The s to was l"n�s ected for sr�rcr� of 'bre Uocat. *," .-- pIL' t >, : _ A�11 ,s Y stem comp ones vs .;' xc, U tho ,SAS have`°b., oc t o y, „;:�r .. if7 .t I.. a ,�,. b f 1 a,.. .ed n t1.1. -. -. -... *.;;. r •�+ 6. �.� rF S f e * }ts N '� S t 'arse sept c taxi man soles we c. ered;' �en'ed,' ands the ii.n6 rior d tt sep�, %c tangy, was inspect'ec �,ond� L `°of �baffleslil� ori tees; }}/ . , , , i. �«� 3 of cbz structaQn, dr�m� r tt� s, dc��� of liquid,°,depth of S• _� 4L.J.e, depth ��*Jf S.Ct�m �� f 5' -,r }, ,.,, , .l f. ..v w 5 t l"u E y v,�J f •- "';sc iz� "and 1'c cation of th`e' 5 cn` the' r e has' been deter' ined a��7, .�._ , I. c11,; •� ��ing �n orms ion 4r ap a�iated"may non in. -rus�.ve methods, y �i w , fact 1 ty caner {ands/`occ,'upC.: t ; if -��ferent ,,from ?owner) .w:e�e d� _ with n o7 �ra`tianf °bn 4°� ritenance of :RSDS. f r.�,aper m k t . K' .-. 11 . 11 a 4 t.. - tA'. 't i / ,,4.;5 fr, m'�; of v, . ' -', a- ° t 4 fr , y N. . % , .•f:. ( 5 .1 . ..� - . - .. i-,,, .; _ . .. .. • '1 :. .. 't' - �.y - !, e r !/ y�,� 4,.ta �� i `7F:� �U I 11Stir rt::FF: C. SEWAGE :�D�S�OSAL:--$YBTEM INSPECTION FORM _ d�ART B i� SYSTEM INFO;RMATSON r fr v'"� T. +z: 11 FLAW CONDITIONS A ,:�,_".'11,1"`., 4 P } grill t li-111i ; .: If re d'er�ta.al, I1t1�Yt�e _o'f peCla:�^4 .ASS , w u-nher of: �." 4s : " .� �, :resI .idents a f is garbage g � Hca ; yes LCrr no `I�c�rldry co ,�,y d 'to` '�yst!em, yes or no (,-ods �' e�2�w �� 5 ,,St. .oval u; Tes:';or M `o ry.- - n If no;-'. -, entz� �, '� , o culated flow .r :. t G' .l� r. , water 's17s er read ;� ,` ?1. .f a aiaal le , , . .. , , t yr , a s r cI. �Ye of occupa. cy , �'� r s A XV+ r i1. f t t Y I'llGENERA, ,'IRk�q FiATTON, f — j $�\ r rq 5 rx se. 1 _ 1 w Pum i} 1. ' p � cords aT� , �r 5�7 7rce� ofY �n artation:, ``" ' , Sia- / x .(`;r 1{Y�<//_� /y 5 r P .�r s f kl� s �r _t`pumpt � �' f art' 'of inspection-;, yes or`no + case r, for $af s + _ t.. 'r j.3 ✓ fl'. ,t i 1,14 'i a ti Kt a t�.. .3 y _'s `.fix 1 ,� t 4 S w t q>f a x r Sr c �,S M.€s ' D r f > 'r`�i,ti f Type, o system` r. t S v �? r t F r�� u� a {rF = . F5 '� ' �,c o�� c tank/%V �. � uon box/sailf absorption syr" em ,. n+ 3,, ° '< F4 , -a f t is A 'i ,! ';i. ngl ces= S,c' � a S:r.: as c 1.`:,4'.Itx�A s ,Mi z s f r a $t t r 14 is r't: F ` tlis � erf.�ow ce r yW:k� i `; R fi 9 �,, ., �f f d '+ p 1 }e 1 Y 1 9. 1. (� r - .Y'.: Y ,f �"3 d �.V y` _ `ay t ;Shared s` s�E �, °s or : ; _ 'i I f. Y s e t a a. t ch r Y e �ous' ins `ecton /��+.� �+ y� P I., Cr 4iVrds 1 lr„tli� l Y A p <" rs�(seer '(expl „- ' ' i F -� _ App�r.°:7mat age 0, '� ,. ��omgonentS. date installed, �� known. Source of 3 r; + c y5 �>, LVA j § z " �F r� Llai - A c.r' 44 f.,.Y.'A f .,, _ t fj r '�»ik i'" hF a , S1 I n Y " ` k f �aag� odorst�l c�' - �.edwhn arrive n ' at r k, d j r,P 3.f fi they site, : yes ;or ro f f f 4 5 �^ 7 fi.. k�(� O l t y i i i F, t Y . .. r'. f f- .*. 1 .i; '1 fi 4 .« q 7 ''c'+. 4. .e if f�, T '1i n. - t j .. r - J . .v . I . I . �� r INSPECTION FORM SUBSURFACE:".l E�TAGE DI6POS..z SXSTEM ,,Y r PART B1. . r STEM` YNFO t R 'oN con inusd b < ^n h K y :,'l i. 2 �'` OPTIC TANK . �( 'Odat� on site. plan) t r t 'S , /l O �k�dep, . INbelow gracie:�.�_ ... 6 s. V �r ;mater __ of construction concrete I'm1. _ FR I mother{explain) 51. �, ': - 1 T.• X4.1 i �m:Y 3 ,. k d�mem lons .. _. .. s�udge depth z '� 1.�� i stance °fr;om torp 4x sludge to boomI. of outlet tee or `baffle = rum thickness _ -di stance from top G`� scum to 'rtop c�a1. outlet tee or �ffle' distance. `from z�lbottci of "scum toc:tom `of ou"tleI.t gee ar baffle - ,r,, _:o x ,,4-.. men , f t I. } , (re coa,en1.datan for pur� a� ng; condritlon of inlet and out .tees' yr 'bafflesr , depth ��tT_-f l lquxd level 5 :'relation . c;4� let invert,. s1.t tt Mural integrity, ";peva," 0,���;e'- of leakage, z:re� Yunendations �r repairs, etc. ); 3 _, 4'C r t N T4s•• ;vim 7'� � . .G2 ti f L�r�r� �S" ¢.0 Eti° a � �tsT.9LL 7ti0, , �- -� r S,F�.--�l c ^� •�` — l.vc.c 7': l' ,. �`1.Z 7 �a °�; F€E-r�r s TD .. ... _ • .. .. , .. �' . d ... .. ., : : f GIS°..�_ BUTIO.N B x: (lay' ' 'on s�to planj' f C Y ; 4{ � t .' f��pth of quid `level 'abo re routle.t invert y .�v4�+�� 4 ' f f f 1. Y l� ,r'�((yya,l �•• i >i l `;-Sf V.�b'l�tt �`4S '�! s �" Y�;.,S ll ,. �, (knot « f lev:� 1 and dais butlon is egU I" evidence .of sc�' ids carryover, eve:�rz of ;' � kage t`inx - : or out off bci : recomziiendation` ®r .'repairs, ' etc ) ,, 1._'�t'_ H't�r '�- 4�TZ.F7 ('e f �� U.�Jb PIPE Li41�t_5 .Tir osl .... % ..i .: . . d .. :.. .. +; - _ y - ,. : 1. I1':ti PLT -aj,P,. ER• (loc a, on 's te.. plan) y a i_,A �, 11, pumps in worltl^� order, y';es o no IF Y .h V q Wt �e 17". �MP Copt 111 ta.�•F ,� f k - Y n i k' n7,7"o• rxondita on of um� hambef cond' tion 1 11 11 of5 pumps anc� appurtenances, ( p. :1 , E F fie ,, �; ndat �`s ::for mat tenarice ,u ze e Xrs,etc ) 4 v. xv A {" 'td 11 M� I, * , . j wI A w ; �3X,.5 C,✓. y la11 19 iq. �,... •Lf Yi Y N ji 4 k " ,i Y 4 y T 4 �iM y % 1 et t J ,' f )� 4 t t�` t M. N t: 4 X yr -. .. -, } :f} ` 1 } tl J 4 } ,v I.SsF i .. 1.1�1 ,+ 5r1. lr>,l' Y ,t ,91;1 .r M. io- F , - iF. - .,tt. .:., f { . ... .. aI . :'J k5.. ... _' .. . ` ^V . _ - „�4 UB$URFACE "P ' � .. -� L�Z$POSAL� BYSTEMI IPJftPI `$SON FORM q.J r a f, �r {sf� tri ( ��F � cti4Ffy�f� ' �C 71 Pl, ZQN conti�uece f 1, 'p a7 r }'T`-j-J {(�A D{qy.,, :N n [� ^+44 y fJ( ( f 4 1 ( C F t 1`L nil yr P�0�L�('�t`W�4%7�,6k ��O`.n 17�✓m+3i�1 1� � A not r �} f & t , S D F .11 �t J � e^r�'� i tf �F.,� (1,a a e on,� sikte; p�'an' fi ' `.;y a ss 3x;.> �'CaV3t`lon ?a int - f f refd, but may,be, �'=apprftlmated by non ntrt rr ► thacPo T""kH�y {'.{,' ,,, h iii ..dy�,y Y W s r ,t, ; t r S� t } - >¢, ''1.1 f> S Y 4C 4 C _ Y1 'j. 4 1 F - 1 f ,� ,- h�, Tf no. determined to be £kt qtr exp~ , ain: d ^ °T} }?.ift tl . f J''*!C. "r.-•y+, iS t"t. 7) a 1 F a it r c. 'Kx.xy ^1.S" F+e` N ¢ .�k Z'y r �a t -� N x ti' l ach ng pzt$ ana number r' rl ach ng=°chambers� and nu��1 J _ , k .�r'7 each ng.&gal , es ,,ands n h �� `� �� l eachs'ng� trenches n.mb:e� ; lgth ;,: k,; �>F leach f f`Zelds nuinber.y , F ksi cans g t /S�X F F,ove .__ c,---i ool, ,numk�eP °'Comment's . ° ', r .. r`f�(note Gond` t ori o soa:l', �, of hj;.lraulic 'faj lure :�4�ve1 of:;ponding, s candzt�on '4�F vegeta`t�on, c �menda . ans' far mazric}. w;��e or repair.`s,ete r iO �-. G'Jr✓f F - _. x r r' % J ,1�,Sc r� i D cs 'cst.yl f S t«i� k�L / S /1 `f: k .F%.uk Fr f L.w syr i Y`^'`" .1 a y i 3 P A P F H CESSPOOLS ( � ocat, on ��t n), 5 R R 1, .. ` �`Gnumber' andonf'igurat�on ` � &;14ie.ptYi � opo lxquzd-,to ].r` ' t• avert �. ,�d:eth of so?ides 1 ay.er ° `depth Lb'V, scum 1°ager `,dmens "ons ;af cess ool r �, ,k s a ------, _._ marials of constPucti:on .:4 - - ,• F ind.icata�on :of •groundwater 4 ur -N_ "t i' flow (ce'sspop.- must be w � ped as �� ,�r p rte of a nsptectJ.onj � 1t :__ £ N C 4 1 Cyt k '' 4 s b -.A �` '�,4Camments 3 3' f (n'�e tcor"dtipn of soy 1, s ^�:s� ?o,f by �auflic failure, veli of pandng, x; "�corr�xt on of vegetation,` r4 �t ��erdat �-ins 'far :i�lai;z en�f° a ak r a�.�s,etc t } . �} F r. , .• • :k J, , �. :PR. JX sa �: `411 pcate on site plan) M Ln G _ 4 tl}} {Cr 3 1 J b F 5 1 a �r materials of constructs on r °. a ,A f P ,dArr ns�a ons >, a � 3 q ' s `i,,', - pth� orf So'1�CSS s i a v e ' s i ��} L 1 /► k �A;°''�Cominentse t ; 3��y�h xt s} C F W,j , L e Kk,s t- T�1,(n:bt'e coradlt�on ofJ `so1l ;:Y s = ,:n }af hyo,,` aulic kfa� .u�� , --ate] pf ypond` 131g, `: eo:n xt i_on of vegetation, r� +:: �mendat ns :tor .mea nt:�na ,o.r repairs,etc. ; `- — .a.. �{.~ t Zy� � ..:; .; i rzerr' y' { a .d ilk,tlt ;�.% ' t a ;,` J u1�3�5m Yyh. J - ,I. ,*$ y,''7"ha Ox k f +. F yr M''. a 1 F t if„^ s ,s.:, s '1,.: s. a ,.e j.J � t ,� �r�W � ,�UBSU"�.'"ACE` SEWAGE DISPOSAL SYSTEM��INSPECTION`FORM t _ { ..t�� SYSTEM �NFORMATIQN continued �POSALrkfSYSTEM:�, -`"' �,.;.-,rt, ., ,� .,....--r , a���i��"xnc�.u�e���.k�s to ��' �past $two permanent re�P�rences 1ar�•�.��arks or b�nchzaarks 1 `��p�1F i; �r� �S'.�` �}j3 A� t � � �� L 'f ai 1r5 e° i .,?';'t£F � 3 �� -£ mss.ys. k l { L �' •� �; � ! � i 7• ? i F� \ 4 f� }.i 5 \3 4 bM F �s zra 4tr � r•1 �pt €,-k t, i 1 .� S 1: e - k c tY. t ,F 1"- J f c � t + sn i t' x 7aa �I� r� r• f �'" �� .f� 'S �C '-' � { L•t 3 r f FS �y ! f < h J,V, t F ( Yr'.! Cy.'f{ f & ' �• dj�j, my thY tt Y Ydi Fi+3`1 i1 Jed �' i . �"t, .'�"�'� ' � � �',* r �"f�',p�ti•�'�ljc h�3�� `��ys'} .trti �-� f`� f� � ' k' qr�� , i-F Srr1C�p v •, }.t 3 .",:�' ,? � ,,r S ' '` 3 .ems � � �ti � 4 - a;.er'�L L :a �p t �!'PNI^C,4C '�'C!L'. < it L•/����.t?r4 � ( �{ > � .� 6 f CM1 °' k }��,� �'rt0f• �F�i��r M.O�`,GRc��7NA6�� ?, yttr (�yt{ f � t }l�l}� � F' P0.L 55 `4 + " Y i 5 G , Y.3` <t � � .5 1 y• rt'5- z .+. A l,=b. P as ;.r;S,' Ysy S i..« ,rs� F�� { Y rr+. L tS+ t Y E, h�, t r, I x ,. A .4YS `• 1 t {{ ��, y r..... .T 1 t. •,-yv r- � ^. E ,ra r �-`s t>y x::, ^[C z i .. t J� t a n' { e I P 5` ' d :� w '�. e t .G 'l.t,+ r , + ^� t a J a ->,.. r f SUBSURFACE: SEWAGE DISpoa� "Ye sf . ZNSPEC:TION F.OI2M 1 5 PAR''��C ;` ,ice w 5 FATLURL C uzTERI It'u t7: y �;�F f , +r j + b. Tnd�.ca" + a , � ; r , r,, „y yf no,r a,r net determined (Y, N, or )t, Describe bass s= of s �determination an al11 i,nstanees. Tf vn,a. `dete �t r nlnea e#']-din wh not cT ° r� R +,` ,5,t ,t;F 5 ..>: Si ..�y ,4>3 ,z } � rw� +'s�a'J Y i ?,�i`' k4>'._:c t; 1f: r rs q n* , � � _. .� Backup °f Sawa{c�' e a�nto r s t ti fiaczl1, t A� ;4 sof $4 S `l l' 5,-,41 Y ,'i r..Y?( F .t � ^ 1 1 1' + > 4 t I S 3 y�.. �r ., Y+ �. tryi J n k i �- t xr, f� „t f yt q,. +t`44 1 5P['a�'t,e(' t +. + " ,y} ) f + i'M y +, JNA >•= Y,,{y F` 5 4 } *�,p � schrge`or pondzng 'Qf effluent to ,the {surface `of tYe 'ground, or n �� s�?rfCe, watersr? z ti� t S L i �; e 7 ?! k 4 s /f� 4 P � ,, -.{.a,, _'S '7 r ! 4 T X.' r t h �C�.. 'StGt�C.*ll qui d level �n ;the clistribvtzon >box Yabove outlet nvezt? j t t t 3k t r.. -a t �, .,t J r. + x LI'.lr�uid:h depth a n fces�poo:i <6�� °bel,ow invert or `ava ] able volumes:_1 Mt�� f�':owe *air d' a `ks'rz 4 t2 ."s n �c + 1�� ` -r ;4. 't / C, �'t,.. I f 'M' 'r�t , P a , Recut �d &pi mping 4 wifies ori amore= in ,thj st y ar ` �� ,;, n �nber of tomes 4p ; ,i ���e e 1a um cl F u Septic tank is .meta 1 cracked? structurally'uhsound� substant�al. �4t..',' F 1 y .. .. In il,tratlon� SLlb5 3I7t�"al exf�`ltratzon� tank 'fa'ilure '°imminent =`� + 4: , 4 .,idf+ t r f � zs any portion of the SAS, ,c.esspool or privy 4L be* ows tie high groundwater e. evation;? ,. wll rl�n t.50 r; - feet of �u�face ,water� �b; l" :c . within 100 +feet<o_ �r:facelwatr supply oar tri�SCitary to a surface �i A3 wager gs.upply� ; ""�. ,,w_y f vat t-,<y N "v+ t l .L t , )r t 5 4 , , -.. a. ,. d C ...62 t f +�x r a � within a4 Zone T %,o i a , ' b'j.' well? e� ' z;. . ., } ,�w 4 t J , 4,F t 5 u - �) 9 4 c a k rrr d x s 6 v e n , _ w��1 i . '.fi , feet of '� Bring vegetated wetl_radti or° salt marsh " ,`7 4 � c ,J ,- . �l d r rk x ( �� s an p t, only, got the SAS j ,� t y Y 1 f ,' L k o Y t y b '�' r 4 ,�. n, ar , I 4 1 , > '> �4"k ± wltxn4r5„0 feet o; ,� � Yate water suPely well?` ti3 P r t, s c - t a - 'Mrl y N }S t 4.p ^a - i+ S t'f 4 4 } 1. dl'l t e ? sv n e 4 ,t 'r ,; t; N # :t Y - { I s JL t is d le W f ry'. {,. , tha�Ill I_ feet R�tz� reatel than 50 `fee`t,Flrpm a private water �r + supply well with ri� C. "table waster qual t �, �s?k ' ell <` ` ` �P '�' t h� S n r� ' , tai Y, ana y xrf .the w andt°nit4� nitrog��.. rr , �, tx,?� s a f$�,C, ,.y k - i w" � : 4 r 5 J r�� Sr tE 1s .�µ' a > 7 i r { + 1„ rr _I..�Y r s i'�}% >4 i t- . 'a ,,� yk'f.K + Y 'T I + -4 f w w� ,� � ; �t a'iCs - 3. ,� t .� 1 y �y r .. ,:_ . . r, % M :.y 'r._V4\. t _ .-' 1. 3, ,syr/. . ,� SUBSURFACE SEWAGE DISPOSAL 'S�'ST IM I�?br3FECTI. Fv0_RM PART-:D I. ��;. 1; CERTIFICFP TON MSI 4 +7 k 1 r P - , \i ..� Nan Inspector 4 e�,�c_ tri G'4s�a � r LJ 2 1. y�e Name i 1y, � .� c� ., $ . �ril�✓ ',; ,'yi w/V e..✓ :,. 1 Wc:✓1 .i (,,, Yeti�, ✓1 l� °`� , �J 1 4 y(y -` 4 }�� C n,� ¢ `r Address y, &l&-yam ,., p v F , <536 .U. �u '�uc✓z syr y". ., k :. 6 1. C ,� atiori �Statemen r:1. , 1. ;� f ,that; Ik haeme Vit+ 3canal,ly inspect ca the 4 ag.e disposal :_ _ em: • 11 y,, r thetciress{sand `that �r,e 'nformat�onepo� edil. true, accurate and ollc`orn�� ,, as o ,,the 'time :�nspectI. ion '1�� c tion wa's7. performed ars a"rid �FYr�sm-Aln;dat�.ons��re ga ;wing^ tipgracle, :'.ma ^ ,{, ; and repair are„ , e'o tent with my tra ng ands^exper erica 1.n proZ.Ipera,function and marry � r�� ncetoon1.si6te =age d�spt�sa syatm f 4 A r 1 } iS 1 ., M :.; \ - Cr�� 4 �, ne �V L Y 4, t �� ?aave 'not found t 1�j �nformatlon cahich : �� ztes4 that I.the sy`stem: ' c� ^ s adequately:µ4.prow c ';publ°xO Fh,ea �h or 'tr<c' rrv�ronment as defined c� CMR 7 5.303h .;fazr re c:r1� er'la 'nog valuated `are''as s`ta1.t1.ec? , . �i� ;FAILUR17',E Q,' . � A :sec��lon of `his f4.orm 1. ��avec#eterminers' ' �t, tie, syste fag .1s tc, rot ct, pubs �.c healthnc� °t r, envi orime'';nt fined a n 31" r15 . a it, ;They basis fora thy. 1 Gi Y Y i .� �, ^ ion o f.. thy. aetermination is -:a �v' ded In the A �, 7RL t�1.Iti� ERXA sect ry J f 47A� 6=c Ill S Signa^ture `✓' -e' .} ..' =Y /�y",. r D f df ,` p r c;}`.r, to s'ysteii, owe. . t P ,tt 1 " 1,SV y /1 y� } C 4� r y i 1 L!,, 1. 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