HomeMy WebLinkAboutMiscellaneous - 59 NORTH CROSS ROAD 4/30/2018 (3) lll0/V7;'l
IIS
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North Andover Health Department
Community and Economic Development Division
October 27, 2017 1 1
Address: 59 North Cross Road
All North Andover Residents with Septic Systems and Garbage Disposals
Please note that due to a recent review of a Title 5 Report, your property has been identified as
maintaining a working garbage disposal that is being used in conjunction with a septic system.
The Health Department is concerned for the longevity of your septic system.
Garbage disposals are never recommended where septic systems are used, but if they are
installed,the system must be specifically designed to handle the waste from them; your system
can not handle the waste as designed. Please note that continued use of this disposal could
quickly cause a pre-mature failure of your septic system, resulting in a large expenditure to
replace it. The North Andover Health Department recommends that you remove it from your
home as soon as possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdept(c�r�,northandoverma.goy.
Thank you for taking the time to consider the impact that your current setup has on your septic
system and the environment.
Si?rian
ly,
aGrasse, CEHT
Director of Public Health
120 Main Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov
t, • ,, Commonwealth of Massachusetts
P;. . Title 5 official Inspection Form
'y
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner Owner s Nam
information is + �� „ J�
required for every �-S.Iicel
page. Citytrown State Zip Code Date 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 A. General Information
filling out forms gN'��
on the computer, ,\1
use only the tab 1. Inspector:
key to move your Q�
cursor-do not k'
use the return m
Na4ie c
of inspector
key. .�OWNOOEP
a 3• ,� co
pany Name
C p Address
a�C �,fe-0
City/Town State
!i�l � 4�� ��� Zip Code
Telephone Number License Number
B. Certification
1 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:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evalua ' n by the Local Approving Authority
Inspectors n ure Date '
The system inspec or all 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 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
rs. Commonwealth of Massachusetts ;
_Title 5 official Inspection Form
4
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
✓`�1l1 Yl L i�c
Owner yk
owner's Na
information is _
required for every
page. C�ity/Tawn
State 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:
I 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:
J
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 repair,or replacement
the Board of Health, will pass. P P as approved by
iCheck th ox for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not ase explain.
The septic tank is me and over 20 years olds` or the septic tank(whether metal or not) is structurally
unsound, exhibits substa I infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank i placed with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection i structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than ears old is available.
Y
❑ Y ❑ N ND Ex lain e
❑ ( p blow :
F t5ins-3113 Title 5 Omclai inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
-- Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address.
Owner
information is Owner's NamAA-4
required for every6r6� � aNCQA.' ��
page. Clty/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
stem Conditionally Passes (cont.):
❑ Observation of s backup or break out or high static water level in the distribution box due
to broken or obstructed p or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approva oard of Health):
❑ broken pipe(s) are replaced Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y N
❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ND (Explain
below):
❑ 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):
❑ truction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of h:
❑ Conditions exist which require further evaluation by the Boar f Health in order to determine if
the system is failing to protect public health, safety or the environ nt.
1. System will pass unless Board of Health determines in accorda a 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•3/13 Title 5 Of ciai inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
� V`�VIYLI�Ir �d'ti\
Owner Owner's Na
information is
required for every
page. Cityfi own State Zip Code Date of Inspection
B. Certification (cont,)
Z. System will fail unless the Board of Health (and Public Water Supplier, if any)
termines that the system is functioning in a manner that protects the public health,
safe nvironment:
❑ The system has a s nk and soil absorption system (SAS)and the SAS is within
100 feet of a surface water sup p ibutary to a surface water supply.
❑ The system has a septic tank and S d the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the S s within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less,tha 00 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
I
*'This system passes if the well water analysis, performed at a DEP certified laborat , for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate ni en is eaual
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the an sis 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:
I
Yes No
❑ � Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 2( 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 %day flow
15ins-3113 Title 5fficiat Inspection nspeUion Fo!rn Subsurface Sewage Disposal System•Page 4
of 17
Commonwealth of Massachusetts
01iTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/u-,- �-
Property Addr
Owner �✓�'V1Y11 "1
Owner's Na e
information is
required for every L`` �� VIM- o•p ... � ---
ire i �S
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ rV1 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 of 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. [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 g and nitrate nitrogen is equal to or les
g q s 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.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10 000
gpd.
❑ 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
9 y system must serve a faciliw'
design flow a
ty
g ow of 10,0009P d to 16,000 9P d.
large systems, you must indica either"yes" or"no" to each of the following, in addition to the
que ns in Section D.
Yes
❑ ❑ e system is within 400 feet of a su a drinking water supply
❑ ❑ the sys is within 200 feet of a tributary to a s ce drinking water supply
❑ ❑ the system is ted in a nitrogen sensitive area (Interi ellhead Protection
Area— IWPA) or a apped Zone 11 of a public water supply w
If you have answered "yes" to any question in tion E the system is considered a significa hreat,
or answered "yes" in Section D above the large sys has failed. The owner or operator of any e
system considered a significant threat under Section E o iled under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system o should contact the appropriate
regional office of the Department.
t5ins•3113
Title 5 Official Inspection Form,.Subsurface Sewage Disposal system•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste orm - Not for Voluntary Assessments
Property Address
Owner Owner's N
information ie
required for every btf�. D`r ' c5v(�� ��� G� �S /U
page. City/Town State Zip Code Date of Inspection
C. Checklist
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
❑ 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?
❑ 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?
j$ ❑ Were all system components, excluding the SAS, located on site?
Q� ❑ 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: X19o4saer-a
Existing information. For example, a plan at of Heal
❑ Ivi
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5))
D. System Information
Residential Flow Conditions;
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
NO S
Property Address --
Owner
Owner's Na
information is nJ
required for every /_Ut.t^-
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? Yes No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes 5< No
Laundry system inspected?
El 01No
Seasonal use?
❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)): AJ A�A
Detail:
Sump pump?
❑ Yes K No
Last date of occupancy: L�.hK_f
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
De�stgfl, w(based on 310 CMR 15.203):
Gallonsr da d
pe Y(gP )
Basis of design flow (seats s/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?.
❑ Yes El No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if avai;abie:
151ns•3113
Title 5 Offiaal Inspection Form:Subsurface Sewage oisposa!System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Sys em Form - Not for Voluntary Assessments
'4 A)
Property Address
/44(LVLI+'It 1 t1�1
Owner Owne Na aA�� O-
�� _
information is (A—
required for every ,�
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records: 1
Source of information: u
Was system pumped as pari of the inspection? ❑ Yes No
a
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Ok Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
Shared system (yes o no) yes, attach previous inspection records, if any)
❑ Innovative/Atternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
15ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ac.0.5 S
Property Address
/1 VL/l i h
Owner Owner's Na
information is
required for every 6I`^v` ` t� l��{ 1 — —1 ?
page. City/Town State Zip Code Date of inspection
D. System Information (cant.)
Approximate age of all components, date installed (if known) and source of information:
co/
Were sewage odors detected when arriving at the site? ❑ Yes KNo
Building Sewer(locate on site pian):
Depth below grade: it
feet
Material of construction:
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.):
/U 1<s
Septic Tank (locate on site plan):
�l
Depth below grade:
feet
Material of construction:
Kconcrete ❑ meta! ❑ 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: �� Xl
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts >
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address T
Owner
owner's Nerro
information is /J
required for every /�'� yr oon& z� o
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
r
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 4,511
+1
Distance from top of scum to top of outlet tee,or baffle
Distance from bottom of scum to bottom of outlet tee or baffle /l
How were dimensions determined?
Comments (on-pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
/°V ' 41
Grease Trap (locate on site plan):
Depth below grade:
feet,
Materia construction:
❑ concrete metal ❑fiberglass ❑ polyethylene y ❑ 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
i
Date of last pumping:
Date
t5ins•3113 Tale 5 Otficial inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
. . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
S-17 61.1 Lit �✓Lt�SS
Property Address ` ---
IC9 Vl OIL 1%A
Owner Owne s a
information is
required for every I-S2z>
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 tim inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal [3 fiberglass ❑ polyethylene
El other (explain):
Dime n ' ns:
Capacity: _
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Da
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form*Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts t
Title 5 official Inspection Form
ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Addre -- - --
Owner
information is
required for every �' at/'L �f
page. c4frown State Zip Code 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
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.):
J4 CXft!,
QA4,14 e-Lti- LIf
Pump Chamber(locate on site plan):
",Pumps in working order. ❑ Yes ❑ No*
Alarms in order: ❑ Yes ❑ No*
Comments (note condition of pu mber, condition of pumps and appurtenances, etc.):
I
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
1 t5ins•3113 Title 5 Official inspection Form;Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
-� - - Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0. A).,
Property Addre s
ti
Owner
Oinformation is
is Na
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
leaching chambers m ers number.
❑ leaching galleries number:
leaching trenches number, length: — C
❑ 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 of
vegetation, et94.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Dep top of liquid to inlet invert
Depth of solids Jaye
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
!Sins•3;13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
y Tale 5 official Inspection Form -
Subsurface Sewage Disposal Sy Form - Not for Voluntary Assessments
L&
Property Address
(L41 t h
Owner owner'
information is •
required for every d%.k
page. City/raven State Zip Code Date of Inspection
I
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
' e
I Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of pon g, condition of vegetation,
eN.
I
IIS
1
t5ins•3I13 rQe 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
i
Commonwealth of Massachusetts
_ -- Title 5 Official Inspection Form
Subsurface Sewage Disposal System For -Not for Voluntary Assessments
Property Address
OwnerO
wners
information is ,�
required for every ��t ��r�'i AA Q tc `6
page. Cityn own 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
1v -s f� o�z
t5ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
L Commonwealth of Massachusetts r ,
Title 5 official Inspection spection Form
Subsurface Sewage Disposal
System Form-Not for Voluntary Assessments
Property Address
Owner Ownef•s
information is
required for every ®h
page. City/Town State Zip Code Date of Inspection
I
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
1/t6A-)q--
❑ Check cellar ;J
❑ Shallow wells v
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:
Date
❑ Observed site {abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
+ a Lk.., VT ,tiokl g
Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
Y must describe how you established the high ground water elevation:
lid
1
I '
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3113
Title 5 Oficial Inspection Form Subsurface Sewage Disposal system•page 16 of 17
i
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
It 6 Subsurface Sewage Disposal Sys7—,7
- Not for Voluntary Assessments
/�c� Q1C4�- -- '
Property Address
Owner � t
Owner' a
information is �'� n _ ( � /
required for every� - 4/t�Y— L/
�
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
I System Information–Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3t13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
r
♦ s • II
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 North Cross Road_
North Andover
Owner: McDonald
Date of Inspection:_1015/21!02_
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.
House
Driveway Water Line
Garage `� B
Deck
Septic Tank
2 1
$1' -►
D-Boz A to 1=3015"
Ato2=23'
A to D-Boz=49'5"
B to 1=32'9"
B to 2=4015"
B to D-Boz=636"
i
Bu 46
- Ot NO eT�14 1'
3:.`. r _�•roc j
_ a
Town of North Andover OEQE File No. 242-488 d by pEQEI
� '•o;,;, ::• F,' HEALTH DEPARTMENT t7obep
'Ss,cNustver
/ C,tyitoWn North Ando se Levis
CHECK#: Ca,St //DATE: �0 -16- 017 Allen Cuscia & i se
LOCATION: S9 �YCJ�T� Cao�z Applicant 1
H/O NAME: Ila-.,- y11r!l
Cross Road
CONTRACTOR NAME: / c
ijtj0(1S
T_yye of Permit or License:(Check box) �s }�r0 2C1i0n Act
❑ Animal $ 40 ter 3.5 A&B
" § + Town Bylaw, Chap
El Body Art Establishment $ wer s
❑ Body Art Practitioner $
❑ Dumpster $ same
ro erty owner)
❑ Food Service-Type: $ (Name of P p
❑ Funeral Directors $ game
❑ Massage Establishment $ JdresS
❑ Massage Practice $ (date)
❑ Offal(Septic)Hauler $ (date]
❑ Recreational Camp $ bruar 22 1
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $ Northern Essex-
0
ssex❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $ date)
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $ tdate)
❑ Septic Disposal Works Installers(DWI) $ -
❑ Title 5 Inspector $
referenced Notice of
Title 5 Report �,5-7 $ sem" has reviewed the above
/ sio�—P loftnation available to the
1e project.Based on thein has determined that
❑ Other:(Indicate) $ e NACC interests in accordance with
e is sig
nil.icant to the following ractice under this
-egulations and precethet
aAcpand ByLaw:
to protection.under
Hea gent Initials ❑
Land containing shelllish
;ontrol Fisheries
White-Applicant Yellow-Health Pink-Treasurer damage prevention protection of wildlife habitat
(tion of pollution
.I —❑ .Gro
5-1
FtfP�tivw 1i/1/$7 - - — --------