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Miscellaneous - 57 MILL ROAD 4/30/2018 (2)
57 MILL ROAD 2101107.C-008'-'0000.0 r, r' As / 4 -; R Vii, -- *. .`:L.�2t_� i1 /�'�.✓ � 7�.� COMMON O X A, D ' mIiV T S Li�S� 4 f t i � I } F i { f a .s Gig► d 10 Irl. �1�s.-_.----"--�_.�.���__ 7 } 1 4 f f 6 ' LL. ..,�+ _t• a PUBLIC HEALTH DEPARTMENT Town of North Andover j {ommunity Development Division Cenificate o f Compliance As of. 19010, 2012 This is to certify that a 5., VSE.ACTORT IMPEC` 100 Was completed for the: Com�t� Cacement RCP Lir of a �Di'st�i6ution Box—�P'i — B on Site Wastewater�L osaCS,ystem 'By. Cl __ja6Conk at: 57 WilrRQad Parcel ID :210/107.C-0086-0000.0 XorthAndover, 90 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the On Site Sewage 0isposal System wigfunction satisfactorily. l us n T Sa -er, X0fS1QrjU bfic?feath Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com • SETTLED 7�e . • bRxTen7►'�`� North Andover Health Department _ f Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFOR ATION D—�� / ADDRESS: 57 �' ,� MAP: LOT: INSTALLER:CI� DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on _ compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by testing ❑ Inlet tee installed, centered under access port e 4 ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank 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 ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing Comments: F] Hydraulic cement around inlet & outlet CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box ❑ Inlet tee (if pumped or >0.087foot) ["Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: North Andover Board of Assessors Public Access Page 1 of 1 poerp ®rth over Board of Assessors 1SSACNIlSE� roperty Record Card Parcel ID:210/107.C-0086-0000.0 FY:2012 Community: North Andover MIKE Will! 0 Click on Sketch to Enlarge Click on Photo to Enlarge 57 MILL ROAD Location: 57 MILL ROAD Owner Name: SEYMOUR,JOSEPH&PAULA Owner Address: 57 MILL ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:5-5 Land Area: 1.04 acres Use Code: 101-SNGL-FAM-RES =Total Finished Area: 2280 sqft 1 Total Value: 428,400 428,400 Building Value: 230,800 230,800 Land Value: 197,600 197,600 Market Land Value: 197,600 Chapter Land Value: Sale Price: 560,000 Sale Date: 09/16/2005 Arms Length Sale Code: Y-YES-VALID Grantor: LANDAMERICA ONESTOP Cert Doc: Book: 9769 Page: 278 http://csc-ma.us/PROPAPP/display.do?linkId=1896541&town=NandoverPubAcc 7/2/2012 LEDMa Block-Lot Commonwealth of Massachusetts 1oi coos6 • BOARD OF HEALTH -- ------ ........ Permit.No k 8: North Andover BHP-2012.0686 FEE ., $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Chad Jablonski to(Repair-D-BOX&PIPE&BAFFLE)an Individual Sewage Disposal System. at No 57 MILL ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2012-068 Dated July 09,2012 ----- .----------------------------- ------ --------- -- ----- . Issued On:Jul-09-2012 !� -- J i - a< °;T; Application for Septic Disposal System /?I Al �pConstruction Permit - TOWN OF TODAY'S DATE , MA 01845 $ 250.00—Full Repair ORTH ANDOVER 4 D < $125.00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key p to move your [Repair or replace an existing system component—What? 3O� >3A cursor-do not use the return key. A. Facility Information _ I Address or Lot# O 10 L1 �I City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ETGravity (choose one) ***If pump system,attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ 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 _ Q Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information -- 04Ja-> a B .ls�. ► ,,w 3 n,s.c s ` 3 a s c. Name Name of Company Address Cityrrown State Zip Code 1 -7 Y, 3C.A —73 SE. Telephone Number(Cell Phone#ifpossible please) 4. Designer Information Name Name of Company Address Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 s f NORrN ,gplcafion for Septic Disposal System TODAY'S DATE A - Construction Permit - TOWN OF �'' Full Repair ORTH ANDOVER, MA 01845 $225.00- '�'°•,„° ''`� $125.00-Component 9SSwcHus�t PAGE 2OF2 A. Facility Information continued.... 5. Type of Building:,residential 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 iss d b his Board of Health. L/ —7 ' Name Date Applicatio p ved By: (Board of Health Representative 7), Name Date Appli ation Disappoved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump S sem? If so,Attach copy ofElectrical Permit Yes No "Il 4. Foundation As-Buhr. 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 r; t SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: For plans b ^//-,+ (Address of septic system) p y (Engineer) Relative to the application of C' J a 3 (Installer's name) And dated :.fLAI- (UngiinZdate Dated ( 2 12� 2 o ay s ate With revisions dated (Last 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 requesting an inspection without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first(1'� 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&townofnorthandover.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 all 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 simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license 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 of Health staff or 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 solely responsible for the installation of the system as per the 412roved dans No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: l ( Z I z-� 1 (T ay's Date) C_ > _bra 'N3Lo,-sK (Name— rmt ame— i e• ' . j y ++rr1 ll Commonwealth of Massachusetts CSS a -- T01NN of NORT14 ANDOVER '� 'V Title 5 Official Inspection For HEALTH DEPART MENT �L Subsurface Sewage Disposal System Form-Not for Voluntary Assessments", ,{ Property Address :o40, S< ntr�L)r Owner Owner's Name information is Alor,f. d Dove M^ 0/vs' /,_tfn,11 required for every �f"' / ,/^� G (p J� 4` page. City/Town State Zip Code pate of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information on the computer, use only the tab :1. Inspector: key to move your r1 cursor-do not J� 3 Bonic2-(C use the return key. Name of Inspector ---- - r�2t t� laorf{CL�/�i1 S(D� o � V«tl� X�n�c ------- ,, Co Lp any Namei O it 1 Compa}n�Address ll City/Town — 2 Stat Zip od 3 —-- -- (oc�os1y©i� Te ephona Number License Number B. Certification 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 the inspection. The inspectioi! was performed based on my training and experience in the proper function acid maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority /Iec—to Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of USC- at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page l of t.. Commonwealth of Massachusetts Title 5 Official Inspection.,form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments, _. . si 1�'li tl �� . ._ , Property Address Owner Owners Name �C information is c...:.. required for every "�� � � ()M4'5 �• 3U— page. City/Town tate Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 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 4r repair, as approved by the Board of Health,will pass. ";. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the foilowing statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank a$;•approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y Y N ❑ ND (Explain below): t5ins•111io Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of!7 ' 1 t Commonwealth of Massachusetts 0z Title 5 Official Inspectiorn For "Il a Subsurface Sewage Disposal System Form-Not for Voluntary'Assessments`�'i.K``'``` ' Props Addressnn Owner ��X- Owners -�- NaNa¢¢¢���e :- information is l/` _/1 � � it 1 '� required for every �^I l.�l� V� V page. City/Town 9tate Zip C-od'e �=-� Date of Inspection B. Certification (cont.) B)' System Conditionally Passes(cont.): 1K Observation of sewage backup or break out or high distribution box:due to,broken or obstructed pipe(s)or due to a broken,.settled or uneven distribution box. vstem will pass inspection if(with approval.of Board of Health): �I broken pipe(s)are replaced [.2 Y ❑ N ❑ ;h(p.(Explain below): ❑ obstruction is removed ❑ Y ❑ N; ❑;r,ND(Explain below): distribution box is leveled or replaced Y ❑ N;''::(3 Np;(Explain below): is crii:Jti•i ❑ The system required pumping more than 4 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or 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 public health, safety and_the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts � _ Title 5 official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -- •' tel_ Property�r❑Q-, Owner Owner's Name information is m k /L 1�( 4 7a— required for every 1_I C�.l „��'� VIZ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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, safety and 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 SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 19 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 '/2 day flow 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name ---- information is required for every page. Cityrrown State Zip Code _Date of Inspection B. Certification (cont.) Yes No ❑ 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 SAS, cesspool or privy is below high ground water elevation. ❑ �q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 71 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ( Q 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. [This system passes If the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, Provided that no other failure criteria are triggered.,A copy of the analysis and chain of custody must be attached to this form.] ❑ K The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ;g The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.' E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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(I.nt@rim.Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ,k& Subsurface Sewage Disposal System Form-Not for Voluntary Assessmepts Property Address M v� Owner Owners Name information is required for every page. City/Town taS to Zlp Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"n4"as to,each of the following: Yes No ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ Were any of the system components pumped out in thq previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to.the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) f SI ❑ Was the facility or dwelling inspected for signs of sewage back up? �l ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth;of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board'of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 C1011,,15,3,02(5)] D. System Information Residential Flow Conditions: y Number of bedrooms(design): -- r Number of bedrooms(actual): Ll DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x,#of ieQQms) , .�l; ' C6ov) t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - i } +, p!r �} , ,Itr; ■. `tea' u �d l al � k�, 'pY r Title 5 Off di"Al*n"Spection�" "ar ,yg � r-- �. s - i i�f Ali �ha y�Subsurface'S"'0 Disposal System`Form/- for Volunta�r Assess�n Property Address fayl,�{ t Owner "^ ^ Owner's Name ,: information Is required for every V page. City/Town - - State Zip Code ..Date'of Inspectlon U l D. System Information ,;,::,;i•;, .t:;...p C11641W0 ;U Description: Number of current residents: ..... •-' Does residence have a garbage`grinder? ' ❑ Yes ® No Is laundry on a separate sewage system?(if yes separate inspeCtion`r qt1 €reilJ`'�'''i ❑ Yes No Laundry system inspected? ❑ Yes ❑ No Seasonal use? :t; +3 Via" rt_'y'u EJ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): i�'�'� � !':'" Detail: Sump pump? '! :Jc,_:,:• *it ❑ Yes No Last date of occupancy: ,l; i.i,,• _CC1�(�CN Date Commercial/Industrial Flow Conditions: f Type of Establishment: Design flow(based on 310 CMR 15.203): ' ' Gallons per day(gpd)d) Basis of design flow(seats/persons/sq:ft.,, etc.)' Grease trap present? > ❑ Yes ❑ No Industrial waste holding tank present?` ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ' _; ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 MIS!Inspection Foran;Subvur►apo.SeWaye Dism"System•Page 7 of 17 a�hS+.tli commonwealth of Massachusetts > .•1j "rK'�'t'�yt tr•y, .._#..! x it19S1� �4 c;•a1�T�e•T�,li'r�i ilnl. �M,v 3 Title 5 Official• Inspeetion� r � r 3ubsurfacgr.SewageDiposal System Fp"nc;'bl4191 Yojuttix/ Property Addressr. ~v Owner Owner's Name v information is `" required for every 1 I C�1,r�.��/'P� V� y�L ��,'�;c�,.�",:7V-��-. 1• .• :. page. itYR9wn •,1,;: tats e - . ..Zlp'Code Zp °qf t -D:System Information (cont.) „ nAi Last date of occupancy/use: Date Other(describe below): Gener,�pjlinfgrmatio 21vCt' w of f I t Pumping�Records: ti ;.I': n. : r ,,.it•s,� i, a �#�'�Ctk1�1 rl [o✓r Source of information: Int i VI C`CT pa Was system pumped as part of the inspection? Yes ❑ No If yes,volume pumped: ,,, „ .,gallons ;r •3{ ri::;t:,ll'I 1fi° f5. How was quantity pumped determined? 1133 do r o h —,.u'f '.' �'' (UC-k- Reason for pumping: ✓4 0� i rS6Ccr✓r� Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool , Ai�ff! ,.: � o Privy ❑ Shared system (yes or no) (if yes,attach previprds, if any) ❑ Innovative/Alternative,,technQlggy,attach,:g,.9 pyj9fr��hl��ftialtlt Qpieration and maintenance contract(to be obtained'from system owner):and a copy of latest inspection of the I/A system by system oper�t,Q.�� �� ^• ::.: ❑ Tight tank.Attach a copy of.the.DEP approyelOr; rv �•1€�s =:u.r;l ❑ Other(describe): .. 0;iftraw.s t5ins•11110 Title 5 Official Inspection Form:Subs uriece Sewepe Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G;"7 " Property Address` C r Owner Owner shame ----- information is f /� CAQ"�� required for every �.l V I�� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Gl�)ou.+ Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: (�r - feet Material of construction: X cast iron ❑ 40 PVC ❑ other(explain): -- - Distance from private water supply well or suction line: — feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: t( ---- -. feet Material of construction: ,®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: -- years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts .;•;Ji {� ,: ;° j ' d;,• Title 5 Official Inspection oFor�nr �4 Subsurface.Sewage Disposal System Form-,Not for Voluntary Asses menY�U , 1 ! '' I 1 Property Addressr Owner Owners Name ` information is required for every — n(-Acwpage. City/Town /v� ���c (j�'' 6-30 17- State Zip Code�J Date of,lrlspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36 r 1 n r� Scum thickness a� Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? rncSS,A�G_ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc): Grease Trap(locate on site plan): Depth below grade: feet - ------ Material of construction: ❑concrete ❑metal ❑fiberglass g ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance.fro top of scgm to top of outlet te,e•or,baffle, Distance from bottom of scum to bottom of outlet tee or baffle . ,. Date of last pumping: - t5ins•11110 Title 5 Official Inspectlon Form Subsurface Sewage Disposal System-Page 10 of 17 ' P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assess►mhts"'; S'`7 lrn i 1 f-kO Property Addres. (� Owner Owners Name � ��` --- — ------ information is required for every n,v C ice, 3,0'- I�L— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 • r Commonwealth of Massachusetts Title 5 Official .Inspection ,Form ,r Subsurface Sewage Disposal System Form-Not for VoluntaryAssessmentg; Property Address Owner Ownet s Name �.-. information is r� required for every ()-CAM— y page. City/Town State Zip Code �l Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert �Yo�e� leve' Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ------ _ bi 2Le �GCt Pump Chamber(locate on site plan): Pumps in working order: ❑ .Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ------------------- t51ns•11/10 Title 5 Official Inspection Porth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forma , g�{`1t Subsurface Sewage Disposal System Form-Not for Voluntary.Assesmt3nte; Property Address Owner Owners NameA C A n 1 l� c Q� U r:;:,;• . -- information is every A /�/�^ �� 3v I required for eve �t� page. City/Town. State ZIP Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ;�;•+{i Privy(locate on site plan): Materials of construction: ------ — Dimensions — Depth of solids Comments(note condition of soil, signs of hydraujic failure;)evel of,porndipg;,cpndition of vegetation, etc.): i?4(ir;t.gti.: L t5ins-1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official InspectionForm Subsurface Sewage Disposal System Form-Not for Voluntary`Assess'rn"nti'�a l Property Address Owner Owners Name informationya.t rx" Is f) '—C�l l t ��C.1 O tQ y required for every ' page. City/Town°" State Zip Cede Date of Inspection D. System Information (cont.) . ._ ,Type/ , . .. ,:,,;<+',.;!`°•... I� leaching pits number: 0 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: — leaching fields number,`dimensions: El 1r' G Iii 17•iii.;''.'. overflow cesspool number. ❑ innovative/alternative system t:?i;:;"itri•':i:l Type/name of technology: Comments (note condition of soil,signs of hydraulic failure;`level of ponding;'damp soil, condition of vegetation, etc.): Cesspools(cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No t5ins•11/10 Title 5 Official inspection forrrt Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -- :S9 - k- l � R Property Address Owner Owner's Namen information is , l _ rn� / required for every c� V 1 � b ' 3U- }� page. &y/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately i v\ N L r� 0 S we 1 � i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F,0Mill Subsurface Sewage Disposal.System;Form=Not for Voluntary asses �ierrts Property Address Owner Owner's Name information is ,(� n (_�/►�/� � required for every 1 I� LSI JV 0 � (NW page. City/Town State Zip Code Date of Inspection D. System Information (cont.) : % Site Exam: ❑ Check Slope ❑ Surface water)Wo ®, Check cellar ❑ Shallow wells NO Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: y — Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 44-Um -0e+< �.{- 3.0 _- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form "Not for Voluntary Assessments _- (Y)1y1 -- Property Address ; Owner Owner's Name information is � (���� 3O �a required for every __ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist _.., inspection Summary:A, B, C, D, or E checked inspection Summary D (System Failure Criteria Applicable to All Systems) completed 2/system Information—Estimated depth to high groundwater Q Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f NEW ENGLAND ENGINEERING SERVICES INC April 30,2005 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover,MA 01845 RECEIVED RE: TITLE V REPORT: 57 Mill Road,North Andover, MA MAY 0 6 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office,686-1768. Sincerely � Q Benjamin C. Osgoo ,Jr.,P.E. Certified Title 5 inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA.01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED MAY p 6 2005 TOWN OF NORTH ANDOVER TITLES HEALTH DEPARTMENT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: .5-7 M l t --ort p Owner's Name: * e r,kJ AI Owner's Address:_,s 7 44,l L- iz"e NO2-/ A,,t,,vae1. Date of Inspection:_sf/Z z je s Name of Inspector:(please print) Benjamin C. Osgood, Jr. Company Name:New England Engineering Services Inc. Mailing Address:60_Beechwood Drive, North Andover, MA 01345 Telephone Number, 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: —ZPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Ins�ettor's Signature: � �' r Date• Az. cv The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different, conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -5-7 rn lc c- /�mD ta tOy{ c-f-- Aliof Owner: i'f Gat c rtdla Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NO One or more system components as desar'bed 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. Answer yes,no or not determined(Y N ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution bat.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 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 ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S7 m e r_ rzo,+p N C>al"w /V-Aj D C-y ct Owner: W( 111V C HAV Date.of Inspection:_ zZi G Farther Evaluation is Required by the Board of Health: A/0 Conditions exist whim require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. L. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which wM protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface.water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh :2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the System is functioning in a manner that protects the public health,safety and 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 tn'butary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well, The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance *tThis system passes if the well water analysis,performed at a DEP certified laboratory,for coliforka 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 s-✓►14, Owner: Date of Inspection: j � D. System Failure Criteria applicable to all systems: You must indicate"yes"or"nor to each of the following for crit inspections: Yes No �Badaip of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _f–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 v Liquid depth in cesspool is less than 6"below invest or available volume is less than'/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 SAS, 1 or oesspoo privy is below high groundwater elevation. -- _+G Any pion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. L�_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _Lz Any portion of a 1 or is within 50 feet of cessPoo a 'vote water 1 privy � supply well. r 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.[This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] �J (Yes/No)The system faits.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system mast serve a facility with a design flow of 10,000 gpd to 15,000 hpd- You must indicate either"yes"or`no"to each of the following: (The followinteria apply to large systems in addition to the criteria above) yes no \, _ the system is withdv 00 fact of�trfttlary ag water supply the system is within 200 fit to a surface drinking water supply — the system is,loctited in a nitrogen itive area(Interim Wellhead Protection Area–IWPA)or a mapped Zonedl da public water supply well If you have answered"yes"to any question in Section Ethe em is considered a significant threat,or answered gree"in Section D above the large system has failed.The owner operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: —4-7 yki r�i ;20&c7 IJ 0✓717.1 k-Aj.J>Dcj t-e— AApp Owner: NLN Ka9ry Date of lmpection: Check if the following have been done.Youmust indicate`des"or"nor as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health —Z—Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? _ Z—Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up 7 _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _�_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the taffies or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? c✓_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soul Absorption System(SAS)on the site has been determined based on: Yes no Z _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)ocep )[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: :-'7 en lootny AJ DI L-V Owner: I-/E-t'eei �tlr9.e� Date of Inspection:z2:/mss FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): ov Number of current residents: / Does residence have a garbage grinder(yes or no): Q Is laundry on a separate sewage system(yes or no):.4+e [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): -- Sump pump(yes or no): No Last date of 9geWang- e r-r�� ---------------- ----— — --- --- ---- COh1MERCIALffNDUSTRIAL Type of establishment Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/peisons/sgft,ctc.): 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/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source_of information:_ 70 AA P" pG/. - Was system pumped as part of the inspection(yes or no):_Ap If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X—Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the anent operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): I .Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,S? .A(K Owner. Date of Inspection: 441z zv:s BUILDING SEWER(locate on site plan) Depth below grade: 2- Materials Materials of construction wtast iron 40 PVC dher(explain): Distance from private water supply well or suction line: A--,g Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: ,/concrete metal fiberglass_polyethylene _other(explain) H tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a dopy of certificate) Dimensions: /Sao Sludge depth: p Distance from top of sludge to bottom of outlet tee or baffle: ?;v" Scum thickness, D" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 2o" How were dimensions determine& AA J,4S,)Ae s7 17C Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakages etc.): 29Ny\ f.v 0JA, cvND i7a� C•vra��O/lr Bui S%Yi"✓ll?ruC. '� co��c 1��GJ�-tcfNO i �'-'S+�-«��'t O� nuc �eS. GREASE TRAP:�ftk(locate on site plan) Depth below grade:— Material of construction: concrete metal fiberglass_polyethylene other (explain): Dimensions: Soma thidmess: 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 umpingComments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S7 ,"j j` izo f9 /V O ID 1+'Q190Q U- 44/1 Owner. 149�*Av CtbfAl Date of Inspection: �122�0 TIGHT or HOLDING TANK:&,)±(tank must be pumped at time of inspectionXlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity, gallons Design Flow: gallonslday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping- Comments umpingComments(condition of alarm and float switches,etc): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): z)?( (N 01/-. CCS✓ lZ [ra C ks�%e,p PUMP CHAMBER:�/✓9' (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.): 1 • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .5 7 pi 4y V 0 /Z-T H /A/l 0�rrA-—'(it Owner: HLL-r6s!4' CrfhA/ Date of Inspection: ,L �— SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type bleaching pits,number:_� /'r FS leaching chambers,number: leaching galleries,number- leaching umberleading trenches,number,length: leading fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): _ttAC9 OF Pj-F-5 JAS 1JG/Z �iL c1taG4yCr— c�r t���- flux G— OHm O Sol /L CESSPOOIS: )' (cesspool must be pumped as part of inspectionxlocate 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(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): .PRIVY:, (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 1-716z--0,V c rf4AI Date of Inspection: y/ 2 jos SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. P115 y 2 (2 aLJ F�)q� i ` Pae 11 f g o 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �;-7 Nva 1-f Priv o �,u ,-A Owner: H c:��n� C k rfit.% Date of Inspection: SITE EXAM Slope �°/. Surfacewater Check Cellar pp,) — N O -s i m p pomp Shallow w — ells p C Estimated depth to groundwater G feet Please indicate(check)all methods used to determine the high ground water elevation: 7 Obtained from system design plans on record-If checked,date of design plan reviewed: l E� Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) I Accessed USGS database-explain: You must describe how you established the high ground water elevation: wy4l' /2- -Les 02 US(ss �n�a�cA S w►4 - -0, 9e�o� �s uNS7 R—5 TO a Ef?-2y F i>20 f C yz 1 1 4-[ A Wi i 1.flh �✓ _ lo` ge ". — ft,(Z&76-- nF sT'6AA �� 3Gsema-,C LS i> COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION yaN 0 P pf3 ILI TITLE 5 INS_ CTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: !Y-'7 /V1% LL_ i<D 11J0 QTU /A Aj n JC--j2. � Owner's Name:- \ 2 A e-L e 1 ' Owner's Address: O I L c /2 D flti Date of Inspection:—T4), Name of Inspector:(please print) 9 e C Cis&V d Company Name: C t.-/ 11� G- Mailing Address:_ D: : i FCH W":,)o ad►vim Telephone Number: g 7 s4— F,€3 h /76 9 CERTIFICATION STATEMENT Y I certify that I;have personally;inspected the sewage disposal system at this address and that the information reported below is true accurate and;oomplete as of the time of the inspection.The inspection was:performed based on my training and..eiCperience m th •proper function and maintenance of on site sewage disposal systems.;Tam a DEP approved systeminspectwpursaant to Section 15.340 of Title 5(310 CMR 15.0' The system:.: --�Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ,D The system inspector shall submit a copy of this' pection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office•of the DEP.The-original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments "*'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does nottaddress how the system will perform in the future under the same or different conditions of:use. Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ ,S'7 /ri t. 2 o Owner: V 1 14 b.l- L Date of Inspection: z Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: `,- 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: e;or�more system components as described in the"Conditional Pass"section need to be reply r repaired. ; system,.upon completion of.the'replacement or repair,as approved by;the;Board of Heal will pass. Answer yes,;nq or n determined(Y,N,ND)in the 'for the following statements.:If"n determined"please explain. 'Ihe�septic,tank.is me d over 20 years old*or the septic tank(wheth etal or not)is structurally unsound,exhibits,substantial infil on or!exfiltration or tank failure is` etit:`System will pass inspection if existing tank,,is replaced with a comp g septic tank as approved by th d of Health. ..*A metal septic;tank will pass inspection it is structurally sound,n eaking andifa:Certificate of Compliance indicating that the tank is less than 20 years o is available. ND explain: Observation of sewage backup or break ou high is water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o even distrib 'on box.System will pass inspection if(with approval of Board of Health): br en pipes)are replaced lion is removed distribution box is leveled or repla ND explain: The system uired pumping more than 4 times a year due to broken or o ed pipe(s).The system will pass inspection• (with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: s x Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 FYI ,t:r. go !V�� 2 T1 f fin)O.�JI✓/L �.i4 Owner: Date of Inspection•�Z ��, 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 failin o protect public health,safety or the environment. 1. System ill pass unless Board of Health determines in accordance with 310 C .303(1)(b)that the system is t functioning in a manner which will protect public health,safety and the environment: _ Cesspool o rivy is within 50 feet of a surface water Cesspool or p 'ry is within 50 feet of a bordering vegetated wetland a salt marsh ;.2. }:System will fail tmless,the Board o ealth(and Public ater Supplier,if any)'determines that the'` system-is functioning in a manner that pr ects the publ' health,safety°and environment: The system has a,septic tank andsoil a t system(SAS)and the SAS is within 100 feet of a -surface water supply or tributary to a-surface supply. r 1 :.The em has& tic tank.a ld`S and the — .� �P AS S is within a Zone-1 of a public water supply. . The,system has.a septic tank a SAS and the SAS is 50 feet of a private water supply well The em syst has a septic/tdnk and SAS and the SAS is less th f 00:feet but 50 feet or more from a private water supply well*!" Method used to determine distance «This system passes/the well water analysis,performed at a DEP certi laboratory,for coliform bacteria and vola 'le organic compounds indicates that the well is free from lution from that facility and the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m,provided that no other failure crit are triggered.A copy of the analysis must be attached to this form. 3. ther: Page 4 of 11 +�� ...tN. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: b 7 M 1 L-i— 12 7 /UJ 2 i N t}M191._,1y0/L Owner: 111C1111(— 4):�Lur-rj Date C 11l — Date of Inspection: o D. System Failure Criteria applicable to all systems: You must indicate`yes"or`Sno"to each of the following'for all inspections: Yes No I Backup of sewage into facility or system component due to 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 1. 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 %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 SAS,cesspool or privy is below high ground water elevation. ., '. Any portion pf cesspool or privy is within 100 feet of a surfacewater supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1.of a public well: ,..LAL 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.:[This system passes if the well water analysis, performed;ataDEP;certifed laboratory,for coliform bacteria;and volatile organic compounds s indicates that the well is free from pollution from that facility.-and the presence of ammonia nitrogewand nitrate'nitrogen:is equal to or less than5 ppm,provided that no other failure critena"`. are triggered.A copy of the analysis must be attached to this form.] The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. e =:large �To be co system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate . er`yes"or`no"to each of the following: (The following criteria to Iarge systems in addition to the criteria above) yes no the system is within 400 feet o urface drinking wa pply the system is within 200 feet of a tribu o a surface drinking water supply the system is located in ogen sensitive area terim Wellhead Protection Area—IWPA)or a mapped Zone H of a publ' ter supply well If you have ed"yes"to any question in Section E the system is idered a significant threat,or answered ,edion D above the large system has failed.The owner or operator any large system considered a significant-threat under Section E or,failed under Section D shall upgrade the' in accordance with 310 CMR 15.304.The em owner should contact the appropriate regional� Dual o>hce of the Dep ent. PProP � i Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l0 t�L. Ro N o fLTH Aa DOOE 2 Owner: d Ic l E 2 EN Date of Inspection: Z Check if the following have been done.You must indicate`yes"or"no"as to each of the following• Yes No ✓_ Pumping information was provided by the owner,occupant,or Board of Health V' Were any of the system components pumped out in the previous two weeks? _L/'_ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓` Was the facility or dwelling inspected for signs of sewage back up-?` Was the site inspected for signs`of break out? Were all system components,excluding the SAS;located on site?. Were the..septic:tank manholes;uncovered,opened,and the interior of the tank inspected for the condition of the baffles br tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum _✓ _ Was the facilityowner and;occu ants if different from owner ( P )provided with information on the propel" maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no vl� _ Existing information.For example,a plan at the Board of Health. .%/Determined in the field(if any of the failure criteria related to'Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 Sti f, T�x a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ;k• �.; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ;z SYSTEM INFORMATION 1 —1 7 ' J I Property Address:_ /VA 1 L L ("0 t' ns FL Owner: V(C-V.1 t= Z A t L C IJ Date of Inspection: * FLOW CONDMO NS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents:_ Does residence have a garbage grinder(yes or no): �!J Is laundry on a separate sewage system(yes or no):TJ_ [if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no): N L? Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): 6�U Last date of occupancy: �.� 2 n r COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd Basis of design flow(seats/persons/sgf dd.): Grease trap present(yes or no) _ Industrial waste holding tank present(yes or no):_ Non-sanitarywaste discharged to the Title 5 em es or no)— Water meter readings,if available: , Last date of occurancy/use: . . ._. . OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: p?jp% 9 -fCW as Q -2 Ow A./C►e Was system pumped as part of the inspection(yes or no): Lfl If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative(Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Pelt- A-C, - tau1Ci Were sewage odors detected when arriving at the site(yes of no): : . Page 7 of 11 ° $ W OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_�7 /Yl i LL go IVv 2nd Alj4>oyr4 Owner. C Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: ✓cast iron _40 PVC_other(explain):_ Distance from private water supply well or suction line: ?_y, Comments(on condition of joints,venting,evidence of leakage,etc.): / '_ isc� i,�_'o k5 SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:_✓concrete_metal_fiberglass_polyethylene _other(explain) If t nk is metal list age:,-.,,,:',. Is age confirmed by a Certificate-of Compliance(yes or no):—(attach a cop of,, certificate) Dimensions: /Sc7 6 Sludge depth: /4t Distance from top of sludge to bottom of outlet tee or baffle: 09 Scum thickness: .0 f Distance from top of scum to top of outlet-tee or baffle: 7 „ Distance from:bottom of scum to bottom of outlet tee or baffle: Zc7 . How were dimensions determined: Y X95 L) g C S Dee- Comments Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,ge,etc.): %F9a a4 AJ c>K Lures D i 17J lJ L'7✓ (ryk tof1'r A tc2�yrc,r�.Ye ���ac,� e cti f_)A C0AjD Ino.y Pc O ..0 C Nl) iN sTi9-dcA--776 )F Gd/l�(kocate on site plan) GREASE TRAP: 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 umpingComments(on Pumping recommendations,•inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): t Page 8 of l l tL '1"a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: , 7 NI,t i- 12,,-) 7y Owner: U t c if,i s Z A Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped 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(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): ;DISTRIBUTION BOX: (if present must be opened)(locate on: plan) Depth of liquid level above outlet invert: O .,,-comments(note if box is level and.distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): TJX /•t/ C�l< �� N.7.T D N• 'it/`U E��OCNCG" l /- S u�.i D3 n*antj ove4 -),2 N .2 vcii PUMP CHAMBERWl-(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Coniments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:- 57 Mi Lw (2,D —__ALQ fLT1-t A a n o Lj E!L Owner: IV Ic 4,t A LLL N Date of Inspection: ? c i SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type __&leaching pits,number: Ieaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system. .Type/name of technology: Comments(note condition-of soil,,signs of hydraulic failure,level of,ponding,damp soil,condition of4egetation,.' etc.): wn,jsPOn�a��v'G- �Ann P SDiL. i32 UA "5V A( V'5(—C—TIS 71c7/lfi =CESSPOOIS:jk)-ff(cesspool must be pumped as part of inspectionXlocate 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(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:It(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 �,yx OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property hAddress• ? M��� (Zo a ,yDojL, ,j)q Owner: V ic y, C Z _LL&N Date of Inspection: Z p SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 3� �� _!lvzic,aZ1DIl Lit Lj- -- Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:-,5-7 /141 L- RI-) lU o 277 .cl c1L 21 1u1q Owner:_ V I c K l e ZALi- N Date of Inspection:/ SITE EXAM Slope S`� Surface water 1V0nc, Check cellar ,��y no 50 Shallow wells N A Estimated depth to ground water & feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:—/q by Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) — Accessed USGS database-explain: You must describe how you established the high ground water elevation: �l brs��.n 2 VS6S D� Cert%s �,. ,9iF 12. O' 6E' �c.� crTiyr,D 3) c ibt .D2 ,,, ENL 0- 6 �OL °`�` ° ° BOARD OF HEALTH n 0- 1... 120 MAIN STREET °"ATF NORTH ANDOVER, MASS. 01845 TEL. 682-6400 �SSACHUS October 22, 1984 Mary VanDevent Lot 2 Mill Road 57 Mill Rd. No.Andover,Mass . Septic Approval Dear Ms VanDevent : The septic system for your house located at 57 Mill Rd. was constructed with the permission of the North Andover Board of Health and was inspected and approved on August 28 ,1984. It should be noted that this approval does not constitute a warranty. Sincerely yours , Michael Graf, S. Sanitary Inspector mg; mj yOVED DATE DI Pik UJED AV.ATI CEJ Ob FA: eascnst — IFIL OK 1. Distance Tot A. Wetlands i b. Drains c. Well 2. Water Line Location 3. No PPC Pipe . Septic Tank - a. . -Tees -_Length k To Clean Ont Govars. - b. Cement Pipe to Tank on Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts _ .j c. No Back Flow V 6. Leach Field or Trench a. Dimensions b. Stone Depth c: Capped Ends , d. Clean Double,Washed Stone' 7. Leach Pit a. DienTons -- b. Stong Depth c. 8p1 ash Pads d. T eef e. Celment Pipe to Pit - Both Sides. f. Clean Double Washed Stone 8. No Garbage Disposal 9. -73.nal Grading .Inspection 10. Barricading Covered System 11. As Built Submitted - Ile a. Lot Location -.- - - b. Dimensions of System c. .Location with Regard.-to Perc Test d. Elevations e: Water Table l Board of Health North Andover,Mass f. SUBSURFACE DISPOSAL DESIGN CHECK LIST �. LOT i 2,gl a La�, 0 _ PPRORED DATE DISAPPRO'PED DATE______, Reasons s rovideds d itle Q eg 2.5 The submitted plan must show as a minimums abutters a) the lot to be served obs ohoieststance to ties b location and log location and results Percolation tests-distance to ties area design ncalculations and dimensions of system-includinons g z� area lei location and f� existing and proposed contours or g) location any wet areas Athin 100' of sewage disposal system disclaimsr-check Wetlands mapping (h) surface and subsurface drains vitbin 1001 of sewage disposal system or disclaimer drainage easementswithin 100 of se ►ge disposal i ( ) location � Board files system or disclaimer-planning this 200' of sewage disposal . (3) kno= sources of Water supply vi system or disclaimer (k) location of aro' proposed well to serve lot-100' from leaching facility (1) location of Water lines on property-10' from leaching facility (m) location of benchmark (n) driveways (o garbage disposals (p no pQC to be used in construction t luanb� pipe, septic tank, (q profile of system-elevations of basemen P distribution box inlets and outlets, distribution field Piping and other elevations (r) maximum ground water elevation in area sewage �sPo oasystem� (s) plan gust be prepared by a Professional Engine ther professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capac t es- ' , % of flow, water table, tees, 'depth of tees, access, pumping (b) cleanout (c) lot from cellar wall or inground swig P001 (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) slope great 0.08 Reg 10.E b) sum ,, a ., a,[, 1 .�` e;;,v'a ,,te< �'+,:" '�."+e'.:v,m +=�t �. �� Y ��!°S.`�r�a�_'� ., 'r�'x•�..}��f` ,*--�.. -. * - +.K � �t� •k y+- `j ,s i r h• -;�w 4 �-+�+; OY.tx' '?.�r :� E r t'�,s �l°" 't + ,�P `!�,.„ n.. ;Y. .'=4k"".-i r ` ... 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M1 y 4'�,C�y"w}q�A2C.� k,• � i t * ' F t v s r F •F X+ _.i ��4,•i•M i,rT y "•. - .r ,eA+r s .` r^'syr.0 7'.n..A H, „ `� t • 4 X t -4 wig Y 'P�• , P'Q `rgkj Air, r t As r4 • �f.r. i Mme i l a, r fi I?`ti+ 'A`a '!`s 'S`/ � P ,SA sr,�'" S[y+Yr .+•a f a b >• •r v..Y t Ti} .n « [; a' .b ¢r r,:t. r"'r, tt .((o-6•F ♦.'� m { lf,.. t r 7 r:t x`4."4 3 �. w%w µ'+Le. PC• ,+ - z F ? .. ``(f .r ;A ",4.t a` +� } ap c 4•e 3 ;� r �.L•t-�� si ,y; AS.af } r k �-.VC ,�„.7...`y'4's`F¢� ; « '-` f.. -' 4 X ^y' ..t I�, ',{•..t'L��'L G�Y r-��,,�" 2 `z A �.jt P1C c, r •'T .�,~ :�' '`rw4 v Y ;a". f !-3ri s.r<,:.,ri.�S A;._"�.p x tY S�t`�"q' Mr jas a7 t �Yx 8 r fF . 1- �\ �� ,� �O��; .' F. S` •s T`r t?�c't'E� k9:i 4 ,�,[ �' x. ,�. S.C.t. A-^ .. -+ r��y v • C `t i'. # ftt ¢ ' L Ar ..e.+�' 3•A t-.F`^ytd • ;.fir ," .... fM .E 'xr-w"�„'°•""�_�`�'a• .l' s P,.'1`R� °' ,r �.A �,,� ie +, .. c - r` i�'• ° t. L ,.',.,1•�. �,It �rM1 wr" t 9 ?a' F d }f Lw ,9 ��.�f 00 y[.ia.. .. R V ,.t.,ro�.^�•}• r�i <fPs;. +' •+ P a`�•` ,•R 4.i.: k Fj y 0 xv ,:, - '1\)`1 ,clOF Af v/� \\O���� ;\U�N I"��Lpt �J�Ot,� ��� WALTER ERIKSEN � No. 762 ED ` �\JCg o • r. �e`wet i 3' 2 J / 9 J � 3 2 1 . 04 Acres * ' PROPOSED 12'x23 ' EXISTING 9'x 16 ' -4 q5� 10 OD 77. 1 1 , 1 1�, 1 h I ` 9 41.3 1. 58 117.10 R 0•N � MORTGAGE PLOT PLAN. MILL Location NORTH.....ANDOVER Scale i in. — 40 ft. Date June .1.5, 19$6 Plan reference: Being lot .2 . on a plan by Robert . Q... Good win.,. R—L.S.. . . . . . . dated April. .12 , .198.2. . . . . . Reoorded in Essex .No...Oist... . . . Registry of Deeds. OTE: I HEREBY CERTIFY THAT THE PREMISES os.P Ion. No..89 8.8. ;S.- . . . . . . . . . . HOWN ON THIS PLAN ARE NOT LOCATED WITH. ............. ..... •.... .... . ................. ............................................ THE FLOOD HAZARD AREA AS DELINEATED 2500 98 North Andover SELWYN & KIRWIN ASSW Land Surveyors N THE MAP OF COMMUNITY NO. .....................j$.'......,,....,_... ...... 14 Linden Avenue, Belmont ASS. EFFECTIVE .J urle...1.,0' ..1`?83................ Y THE DEPARTMENT W HdUS NG AND URIAN I hereb Certif that the budding shown on this EVELOPMENT-FEDERAL INSURAN�CL Ab1�*&-MATM plan is located on the gpund gs awn thereon and that it Conforms to the toning and building laws of the .town of. North. Andover. . . . . when Oona c tp rid _.. is P64 plan fiat liof "do fro(n in inormw � ad k Y sdram for so w 49 moR egoo. for awrlgapa perpowa only. f M Folul U TOWN OF NORTH ANDOVER ��[[ LOT RELEASE FORM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET APPLICANT PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COMMISSION i D OVER CONSERVATION ADMIN. REJECTED BOARD OF HEALTH D7 TE— -/1P-P-ROVEu 25 HEALTH A ' AR ,�j , DATE REJECTLD--.../ ® 7V DEP ZTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and health boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. Board_ of HealthSEPTIC STSTEH ��� � ` North Anwar xH M INSTALLATIcK CHECK LIST LOT'' /VL( l tZ ` AVATI 01EFAIL OYED $ PROVED - Law eam)ns: No r--fes FM � 1. h Distance To s lands. b. Drains c.. Well " �4 0 ( 2. Water Line Location 3.- No PVC Pipe Septic Tank a. _Tees -_Length & To Clean Out Covers. b. Cement Pipe .to Tank- On Both Sides of Tank. 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flo Amg Equal- Amounts c. No Back Flow 6. - Leach Field or Trench a. Dimensions b. Stone Depth c: Capped 'Ends ' d. Clean Double'Washed Stone' 7. Leach Pits ' a. Dinensions b. Stone Depth - c. Splash Pads d. Tees e. Cert Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal Final Grading Inspection lA. Barricading Covered System 11. As Built Submitted a. Lot Location (� b. Dimensions of System c. Location -4th Regard to Perc Test d. Elevations ` e; Water Table `Boar-A of _1th 1 r,Masa S:UBf . CE DISPOSAL DESIGN CMK LIST t4a c'"ts VAJvzpNy tA LG - APPnffi DI SAPPY UflM DATE �, sorest Provided: -. _ c - -Title V - CK Reg 2.5 Ae submit: Ian rrast ahOW as a the lot ` ` Served-area,di.mensic) ..^ .t locep atic'- .` to observation h�� -s - B s percolation te, ' cii s- locatic. result .. - .. design r . 7 ations & calculations b' In b e locatio-• I dimensions of system-il"". din;,_ e�3 sti_��r -3 pro?osed contours Iocatic,j, ; wet areas Within 100' v- - discla_- ' - -heck watlands napping surface subsirfacs &-gins sflthin l�>O t of _ system c,.. .'i gclaier locatio;, �. drainage easeents w{ithi ; 1fJ0 a c - system c isclaimer_Pla-�ng Board f-�' es �) know s- of - ter supply �xlt' � ?(�Q o" y `;4 , s syst-F-_s c ";sclainer �- �- _ - _ �.acati•� a�Proposed-�,-a7.1 to sex . _1.ot_'' - ;° � . _ catir, 14ater l.ixies on propert;�-� cat:io " bPnchr.ark _ - c�i•ce ham o garbage ;' _�sals - no PVC -t: ,e used in construction f (q) profile ( , system-elevations of base di stria `.` _� box inlets and outlets, �'.aI other e' liens - r ir,P��r? � and water elevation in axt S) plan r_5, ' e prepa—red by a Professio! E✓�' profess ' 1 authorized by law to pr re e 6 S�tic F. a c�7::ci. - 50� of f"10ri, S,3tp-r tab access. ,ing cl 10, fn.. I lar X01 or i_ngroimd s,� 'ag d) 251 fr, Js'urface drains Reg 10.2 Distrix, BOxes slope L_. . : tn=n 0,08 Reg 10.4 I b) 't"u w-►s P r�s deZr,v o r_ PVT __L X20►.t [•�s G ©►� ►20�-t pi'r 9nbstLrAce Deni, . „ 21: `list Pay a 2 FA 174 _.._. .. �.• , : fG,, -:d where the installation _ —d b e Reg 11.2 _ , r} ;.:. � � �'-r � �•xg; L �-gym 5C30 sq ft 11.E 11.10 11.E f ? -"3 c-1 :x to pipe leg 15.1 iAnch 15.4 ld 15.8 3.7 _ Y�} �_ � €: �" _�_ or Zraund mdnndbg pool teg. _ C }•Mf;. fr i•J.�e e. 7 't£!1 7 ^.L��'� 5bO sq ft 14.3 �. ,.�} .A 1: . e 1 t Wi,'1 reserve bete 14.4 �} . � 14.6 ST Of 9.1- 9.6 .1 SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No M��� Lot No K0 lk Loc/Subdiv. Pland OwnerUQ-rtt� InvestigatorObserver �� SOIL PROFILE DATES l.Elev 2.Elev 3.Elev 4.Elev 1 0 0 0 0 TimmsPi%s est 2 2 2 2 3 3 3 3 5 5 5 5 6 6 6 6 7 7 G'n 7 7 8 �y _ 8 8 8 9 9 9 9 10! 10 10 10 Benchmark Location Elevation Datum PERC01,ATION TESTS DATES Pit Number 1 2 3 Start Saturation Soak-Minutes ar e Drop of 3"-Time -Drop of 6"-Time Mdms-lst 3" drop Mins.2nd " Drop Percolation �► �4i h �c TO: NORTH ANDOVER, MASS /4c.c 19 64 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System I nspection This is to certify that I have inspected the construction of the.said disposal system at Z/— f-c'j " North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 2 �"' 1 �— 19—,95-4y. COA410 A CD eg. n er/Re �� ni ian 9�i9N S113S��a DU.`.!CL Ur JiL iLlri Town of Yorth Andover,Mass . , Permit n Date - - > 19 APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well (_) . App.lication is made to mall ( ) a pump system. Location: Address LL- 5" . . -Lot # - Owner ,i_01.-- -fDil Address rl�/f c fRC-1 1-2- Well ContractorSt� aivG Addressi�Y /t/ ` Tel . Pump Contractor-67a-Ax Q _Address_ Tel WELL CONTRACTOR (To be completed at time of pump test ) TYPe of Well - ,Q �.='s a'i✓ Well used for Diameter of Well L� `r Size of Casing � !` Depth of BedRock / 4;`0 1 Depth casing into Bed Rock 1i ,5- - Was isWas Seal Tested? Yes ( ) No ( ) Date -of Testing Depth of Well _3a6- Well Ended in What Ifaterial -2 6 r_l< Depth to tater G.5 l _Delivers- 5 Gals . Per Min. for 4 hours Drawdown �)--U feet after pumping / hours at 7 GPM Date of Coletion r n igatue l,ellt Contractor _ - - PUMP INSTA7 R (To be fille-d--in =before- installation)- Size & Name-'Fbmp Pump Type Used-- Water sed -Water Pump IL-livers- . / 0 GPM = - Size Orf Tank Z/G Cly C Pipe Material Used in Well : Cast Iron .(-) Galvanized. (-) Plastic Well Pit (_1 or Pitless- Adapter (CX 1-?as sleeve wed to protect pipe?--Yes (v') NO{_) Type or Dame v.eLl Seal _- Date. ,!..•..t.4.}.,:..':.•..' ' Y-.��`_-,!..• .. -- b t- 3 J; •_ J..•.'1. L 1.: �-L:: rX� .� }. -PPc Tl� ta,I � f ]r i-_ ,• ,, ., ., :: , :S�Z::�n ,il)Y'/„i'i5f.•:,zY5.Yr5r;::�rYr:';ii; r�;,;irir:�;;:r:;'..Si3. x;: :::;;�::;-::;:,, >.:, ,r:r�; r„ii;;�ir;-. ,r)rr; Date V.1ater adalysis report submitted to --Board of Health Date - release given iD owner of record & Bldg. .Insp_ Health ' Inspector e e E e Stevens. Water Analysiss 38 Montvale Avenue • Stoneham, MA 02180 • Mass. (617) 438-6114 • Salem, N.H.. (603) 893-3106 LABORATORY NUMBER 12504 SAMPLE DATE: 4/18/84 SUBMITTED BY: Joseph Barbagallo 1 Westward Circle North Reading, MA 01864 SAMPLE SOURCE: New Well/collected direct Mill Street , No . Andover , MA ANALYSIS : According to Standard Methods of Water and Wastewater Analysis , 15th Ed. Total Coliform . . . . , . . • not requested Chlorides . . . . . . . . . . 5 mg/L pH . . . . . . . . . . . . . 8 .0 Hardness . . . . . . . . . 58 mg/L Manganese. . . . . . . . . . 0 . 15 mg/L Sodium . . . . . . . . . . . . . 18 . 8 mg/L Iron . . . . . . . . . . . 5 . 60 mg/L Nitrate. . . . . .. . . . . . . . less than 0 . 10 mg/L Nitrite. . . . . . . . . . . less than 0 . 10 mg/L COMMENT: The results of these analyses meet the required federal and state standards for drinking water . However, the manganese , and particularly the iron concentration, exceed the recommended standards . Althoug iron and manganese are not harmful to your health, they c'an affect the taste , color and odor of your water : Iron and manganese are frequently found at elevated levels in new wells ; however , it is likely that the concentrations will decrease when the well is put into regular use . P Che ist/Microbiologist e e E Stevens Water Analysi's 38 Montvale Avenue • Stoneham, MA 02180 • Mass. (617) 438-6114 •.Salem, N.H. (603) 893-3106 LABORATORY NUMBER: 13703 SAMPLE DATE : 10/12/84 SUBMITTED BY: Joseph Barbagallo 1 Westward Circle No . Reading , MA 01864 SAMPLE SOURCE: New Artesian Well/collected from faucet Joseph Barbagallo, No . Andover , MA ANALYSIS : According to Standard Methods of Water and Wastewater Analysis , 15th Ed . 1 Total Coliform . . . . . . . 0 per 100 ml i COMMENT : , The result of this analysis meets the fedexal and state bacteriological standax-d fos _d.rinking _water . i I Chemist Microbiologist ry. _A_/_Q. --2)h'A//YS OR, t-✓E tl RND L✓/rti/wI / oo �LQICI - O-!�- -D/. P.GSA SyS�Ei-� ��000sEo Sussu�eF.4cE SEw.ab� /Sf�2SgL c$�STEA? �.pOAAQSED LO r tgR.4,01,VG SCALE - / "c 40 ' DATE - 3 " 1� ' �' �• OwaeAe_.BAR C O CoR P • • -.l WESTWi9/2D c.'/ROLE - - .. .NG• REAyL/NG/ �f1A5S• LocAriow tTO.SEPN .r AARSAg*AZL O , WE3TK/AR46 CIRCLE z No. A 6.44VA14, , MAss. TEz. 46s/G.v oA rA TYPE OF 9&&41A14v 48-R• ZPWEE////VG . GARAGE ¢ CELL4R PLUMB/A/C. AACIG/T/ES= $E!L/A4GE AW W ESr/MATE: G o o G P• D SSEPr�G r4wIc i4QSGi�PT/G�! AREA 6 3 G S F• S!,A //a (A,- 'TS r ZP6RmtArioAv 7msrs 1047LIC, ld - 7-83 !o -7-8.3 TIJIP ELEYAT/ON it DROP MiN M/N. M/N MiN M/AV AfIAI Atif/A./. _ M/A /, - 4 � �RLaC.4 r/oN RArE $' •y�,�.l/u 7 S M.•u�/ �fli�../,u. Mie. /w. TEST PITS �/ �Z 3 ¢4 1� r F.rr� 9 �• o DA rE y� ' 17.E aoA � So' .°` _"'. .-.,o TOP EGEVATIMI q 7.• a 97 S t �� A76 p f Sad t Ss �. u _ . .. � � -•� a r,��' ,, ,�� � so/G T yPEs .4 ti/D 9.1 G R.avc L 9'GRa►vr't_ wALaATT/oNE i Na N N© N r o M• cry q ^� ter, 5 -rO 6�&VAnoAj; g7, a 87,0 -t------- -_ '----- -�...r' r.J `,'�. TE5T5 �ti�l �,rEv Byosr - - _ TEST.s K//THE Wil+ Sy. 45x IAJL N /.2r�04 �' = /oa•c� - • o� �Ji1�IQRf - ��.:iM/11.9TNV6F1itLAA4L�ft'LMC�M-AM<w:,•WOI.ivL.11n•Yfs.Mll.v.I.e•/Ji...Y1.lvNOJGv,.1..l�Xl.'t/110!(AtW.WNV/SN.VI fHAI41.MY..t:Y•.�ut•1?ll t4.•i1'.Vf[:.\`.a<.^ttA•MtJ1f.,a.A.•.rl....-.tw.cin•w'c••M.'hx•u�nws..mam•:n�..r..w-,u.:c.:�.„�w.:r.>::_ .._.._. -a.-.yy`.�+i �.. PRECAST CO/vG,C�ETE PIT wAS,qED L7e6C5 -/oto sro.vE 3/¢"ro//Z !it/ASNED C--Z451-165 ,STONE /Z" SAX//Nc/M COl�E�2 /Z" h1fIX/MG itO COIiE,e, — �LbUBLE K/ASi/E1> -AASHD .SPEC. T-i/-�O� - �wi rH rE�) t,J O O d O O O O 1 CD G`d Z X 2'x.3" CD.vice� � O o 0 0. 33 © O o O d sPL,4-5H PAD 3 O O O O O O O CD ii v o cso o c7 /4.' �EEl�AGE P/T - ECT/O,V A-A cSEEPAGE P/T- 7-10 A/ B-B cSC4GE 3�f3 = �� cSCALE 3t3 ¢"�ICA57-.S20.c1, S=. SE'EPALgE AREA /So v COAL. GD�1G2 ETE SEPT/G TA/lllG t0` ¢"�SdL/D RUC,.SEALE� TO/�lTS� S=.t�.5 � '¢' �— SNAL LOW SEEPAGE Pl r i � 1 i 1 � 45 CO C43 41\ au 0 14 r G '�- • � m,4- 0-11 ate,.` °� cSEEPAGE P1 T — PLAA.1 PRO,, E r cSEEPA,-,E -P/T PLA Al Qrvo SEc Tio,vs c Sk6.ET o�