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Home My WebLink AboutMiscellaneous - 59 WILLOW RIDGE ROAD 4/30/2018 (2)Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rob Commonwealth of Massachusetts .�. �- Y y'k c� vcm City/Town of No Andover System Pumping Record OC►�� Form 4 TOWN V-4 MOR I H ANDOVeR HEAL.'�'H DEPARTMENT DEP has provided this form for use by local Boards of Health. Other for. s Ay be u` sed`=but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 59 Willow ridae Rd Address No Andover _ City/Town 2. System Owner: Robonson Name Address (if different from location) CitylTown MA State State Telephone Number Zip Code Zip Code B. Pumping Record 1. Date of Pumping Date o7 2. Quantity Pumped: Gallons' 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): KNo 4. Effluent Tee Filter present? E]YesIf yes, was it cleaned? ElYes ElNo 5. Condition of System: 6. System Pumped By Name Vehicle License Number* - Stewart's Septic Service Company 7. Location where contents were disposed: Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 a of H u �� Date --- Date t5form4.doc• 03106 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover System Pumping Record M SV a e Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q rznon DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351.- - - '14— --r RECEIVEC 3 A. Facility Information 1. System Location: 59 willow ridge Rd Address North Andover Ma JUN -7 M1 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 01845 City/Town State Zip Code 2. System Owner: Robinson Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 5/20/11 2. Quantity Pumped: 1000 Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: xsolids 6. System Pumped By: Frank Eldridge Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 / Signature of Hau r Date Signature of R66ving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 z ��%N�r♦1,".11'.� �•� i •,`'.'� 57J. +.ii; :,'ref' �t L + ,f� 4„ ' , :•.:w.�'iv.r.r�:'i.ti�.:i��..1..♦4�tG'3:iti�i�r''h;� r;.r•.: '� ��-�•••EDEIVED •��,,.. �4��♦• .... ... DEC 0 6 200 'r•c�w>Y 5 Y 8 T- P {J M P I N O Rp �-;OWN OF NORTH ANDOVER �ALTH DEPARTMENT �Y31'6)rZ o17 M p QR � ��o�ss--'—�_�..._, sy,`.'. eMi:�'.:�•;�''�:,;.� "0, 7111,�MNQ, �/-Z_ �'t��POOt,� Np Y�J,♦ ... - )vauc I'uia n; N� rVK� Cr 3�xvlc,�e; �v'rirr� GOOD CotIrJl'J'Ivlr .. YUU. I'v t;c7vrx eXC&98rY8 �Ol,lpe .♦..r. ��•CF{>r1�1..4 xvNa�c.��. . P�ood�d hoc lD c�► IVB YA Y�iC " ' o me R .e x P L A IN CPO- t'VMM�NT�, � �1r I'�N 1'y tx�lNyr�XxhU I'� Y FORM - U - LOT RELEASE FORM ` 0j eE t 1 to 15 x 40 INSTRUCTIONS: This form is used. to verify that all -necessary approval/ permits from D e c -!L Boards and Departments having jurisdiction have been obtained This does not relieve the applicant and or landowner from compliance with any applicable requirements. /..•......■i......l......lt■....fl.f.......■t....tf....l...t...MESON . some was APPLICANT PHONE ASSESSORS MAP NUMBER % d / LOT NUMBER SUBDIVISION LOT NUMBER STREET 6AJ [ //Ow 02(d V?D , STREET NUMBER OFFICIAL USE ONLY ........................Woods was .................■.........t.....Samoa ... Sam .... RECONINIENDATIONS OF TOWN AGENTS ..ttt.....f.tt..............................■............................mom / DATE APPROVED L/ CONSERVATION ADAGNISTRATOR DATE REJECTED CONIIVIENTS DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INS ECT - HEALTH DATE REJECTED / DATE APPROVED 4 Z !/ TOR - TH DATE REJECTED COMMENTS T PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMfT 1� w._ yuI DATE APPROVED DATE REJECTED CON%4ENTS RECEIVED BY BUILDING INSPECTOR DATE: �T 1 2 13 4 15 16 17 EXISTING EXISTING UV1NG ROOM FOYER/ENTRY K 106 103 - i 7 'H EXISTING DINING ROOM 106 I FAI C 4'-0' 3 6 NEW REF. BREAKFAST AREA �4EXISVG FIRST FLOOR 102 ELEV.- 8'-0" G I EQ. EQ. ' T-0" T-6" - 5 ----�-- - - o ----- - ---- -- - -- - — ------- -- - -- ----- --- -------- - — ------ - c, ------�- -- -- - -- Z 71 ®® wjil z o .I - NEW ! 'i! o 00 UBRARY 100 I ®® Ln ' j Nm 10 NEW j NEW FIRST FLOOR KITCHEN 101 2 ° ELEV: 8'-0" 10 V IF o - 12'- 6' _ 2;_7 T-8' 3,_8, 2,_ I i DW I l 0 o Del. OVEN , L ---J mil 4'-0' 3 26'-0" Al A-301 PROJECT NORTH 8 Al NEW FIRST FLOOR PLAN A- a 1'-°- 1 12 13 14 15 16 17 18 6 26'-0" Al A-301 PROJECT NORTH 8 Al NEW FIRST FLOOR PLAN A- a 1'-°- 1 12 13 14 15 16 17 18 4l f l Zl ll m B L 3AOeV 9NIWVNd 0383A3IUNVO 9NLLSIX3 30 1N31X3 S31V010NI 3NII 03HSVO HSINI3 3NOlS 31 N01831X3 NO ONIOV88 3NA OOV 'MOONIM J,VB M3N NIH11M HSINI3 dOAMNf100 IIVISNI N3NMO3WOH H11M S3HSIN13 NOOl3 M3N 31VNION000 JNIOVdS V SMIS WV38 80d NVId JNIWV8d Ol 83338 'Sl80ddnS 38(11 ONOS 9NLLSIX3 NO 111(18 38 Ol NOW Id M3N (IIV8 A83A3 1V IVOW I) OVOI IVN3IVI Sel00Z ONV1SH11M ONV 'HJIH „9C 38 Ol SIIVN (08Vf19) ONVH IIV (,LL (IV38l/'XVW „L 1HO13H d3SI8) )13H 80013 1SHId MO -138 „Z 'I3A3I 8030 Id Ol do Sd31S M3N '00118 ).8 SN000 OV3HXIf18 M3N (83NM03W0H H11M 3IUS 31VNION000) 3ILLS-(181 )l8 k8v8en OINI S8000 3I8f10O H3N383 M3N JNLLSIX3 H11M NJIIV ONV H31VW Ol 9N1800-3 O0OM08VH M3N IIVISNI 03AOW38 SVM 13SOI0 .uniin ONUSIX3 383HM SIIVM IIV 81Vd3N 0NV HOlVd (NOLLV1N3Wf1000 83NDIS30 WHO11N ONV 8010V81N00 HIM 31VNION000 Ol 83NM03W0H 'ONLLHOII ONV S13Nl8VO 'S831Nf100 'ONINOOI3) NOIS30 N3HO11N M3N 3A08V WV38 1NOddf1S M3N 803 Ai AVO IIVM NIH11M S1SOd 180ddf1S *Xv IIVISNI :310N 90l 30VMV9 ONLLSD(3 VLJ et] Z� F0 �❑ �9 m `1 1 IN ❑i F Ft d N3A 'I8 1 tiol �12 w9 -,E ,0-1c M008HIVB 9Nl1SD(3 Z0L BbaT�7 V38V 3NNV388 i 0 7071 M008 A11MN.i JNIISD(3 ll oil 61 91 L d V O r UA t'k �/W I RECE71VEJ) TOWN OF' LTH AN*DOVER D NOV NOV — I Inno SYSTEM P MPINQ RECOR _ I)nno SYSTEM OWNER & ADDRESS (A� Q531 e TO vEp SYSTEM L67CATIO m DATE OF PUMPltqG:___, QUANTITY P I UMPED 7000( CL5SPWL: NO--_ . YES'. S00C Tank: NO YES NA PURE OF SERVICE: Kc)u-rINE'N EMERUEN(,y OBSERVA rIONS: GOOD CONDITION_FULL *TY-) COVER HEAVYoREASEIN PLACE ROOTS LEACKFIELD RUNBACK EXCESSIVE SOLIDS__.__. FLOODED SOLID CARRYOVER _ ......... . OTHER EXPLAIN System pwnpcd by .. .... Lso ,77a. �'()MMENTS. *1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 59 W i 11 o,-, B iocz a Rb iVo"-r 0oE- Owner's Name: TRkc-%A w ,f� fL tt l N CrE2 Owner's Address: N o tz A" o z, , e a - Date of Inspection: yj�Z o a Name of Inspector: (please print) _ 3 cn; /iM i !2� ( 00 p 0-2 Company Name: -Mew �, G iqN n ENW ti EC2t o Cr Mailing Address: loo Telephone Number. 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;oomplete as of the time of the inspection. The inspection was performed based on my traming and eicperience 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 15.064 The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 8 o Z The system inspector shall submit a copy of this in 'on 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: _ TRICIA WARRANGER Owner. 59 WILLOW RIDGE ROAD Date of Ins NORTH ANDOVER, MA 01845 Inspection: _ y`3/0 2 Inspection Summary. —. ... „ A�vvam__ all of Section D A. System Passes: V 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" exist. Any failure criteria not evaluated are indicated below. Comments: B. Srtem Conditionally Passes: un more system components. as descn'bed in the "Conditional Pass" section need to be ced or repaired. The ,gin, upon completion of the'replaccment or repair, as approved by the Board o ealth, will pass. Answer yes, no or not ermined (X,N,ND) in the for the following statemen "not determined" please explain. The septic tank is metal over 20 years old* or the septic tank ( er metal or not) is structurally unsound, exhibits substantial in 'on or exfiltration or tank failure is ' inent. System will pass inspection if the existing tank is -replaced with a comp. ' g septic tank as approved by a Board of Health. *A metal septic tank will pass inspection.' it is structurally soun of leaking and if a Certificate of Compliance indicating that the tank is less than 20 years d is available. ND explain: Observation of sewage backup or break !u static water level in the distribution box due to brokers or obstructed pipe(s) or due.to a broken, settled or even on box. System will pass inspection if (with approval of Board ofHealth) bro pipe(s) are replaced o lion is removed distribution box is leveled or repla ND explain: The system nred pumping more than 4 times a year due to broken or o cted pipe(s). The system will pass inspection if th 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: _ TRICIA WARRANGER Owner: — 59 WILLOW RIDGE ROAD Date of Inspection: _ NORTH ANDOVER, MA 01845 C. Farther Evaluati_.._ _ .., ........a..1 va acuttn: Conditions exist which require further evaluation by the Board of Health in order to determip�if the system is fa ' g to protect public health, safety or the environment. / 1. Sys m will pass. unless Board of Health determines in accordance with 310 C 15.303(l)(b) that the syste not functioning in a manner which will protect public health, safety nd the environment: or privy is within 50 feet of a surface water _ Cesspool privy is within 50 feet of a bordering vegetated wetland a salt marsh 2. System will fail unless the B of Health (and Pab ' Water Supplier If any) determines that the system is functioning in a manner t protects the p c health, safety and.environment: The system has a septictank and 'l on system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a ter supply. The system has a septic tank and an a SAS is within a Zone 1 of a public water supply. The system has a septic d SAS and the is within 50 feet of a private water supply well. The system has a tank and SAS and the SAS ' ess than100 feet but 50 feet or more from a private water supply we •. Method used to determine d' ce "This system if the well water analysis, performed at a D certified laboratory, for coliform bacteria and v atileorganic compounds indicates that the well is fr from pollution from that facility sad the presen of ammonia nitrogen and nitrate nitrogen is equal to or 1 than 5 ppm, provided that no other failure teria.are triggered. A copy of the analysis must be attached to form. 3. Other. i Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ TRICIA WARRANGER Owner. - 59 WILLOW RIDGE ROAD Date of Inspection:.' NORTH ANDOVER, MA 01845 gIN011 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 t/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ! Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, t: performed .at a DEP certified laboratory, for coliform bacteria and volatile organic componuds 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.] NO (Ye& No) The system fails. I have determined that one or more of the above failure criteria exist as descn'bed 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. rge Systems: gp. co ered a_large:system the system mast serve a facility with a design flow of 10 gpd to 15,000 gpd. You must indicate a er `fires" or ` ho" to each of the following: (The following criteria ap to large systems in addition to the criteria a yes no the system is within 400 feet o ce er supply the system is within 200 feet of atn�usutface drinking water supply the system is located in ogen sensitive area (Int �elfliProtection Area — IWPA) or a mapped Zone lI of a publ' ter supply well If you have atwered "yes" to any question in Section E the system is considered ' ificant threat, or answered `fres" in Section D above the large system has failed The owner or operator of any larg em considered a significant threat under Section E or failed under Section D shall upgrade the system in acro ce 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: _ TRICIA WARRANGER Owner: 59 WILLOW RIDGE ROAD Date of Inspection: _ NORTH ANDOVER, MA 01845 Check if the following have been done. You must indicate `des" or "nor 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 ? ✓� 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 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: Yno � _ — Existing information. For example, a plan at the Board of Health. VDetermined 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 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: — TRICIA WARRANGER 59 WILLOW RIDGE ROAD Owner: NORV09 ANDOVER, MA 01845 Date of Inspection: N� FLOW CONDITIONS RFSIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t- 0-21 Cs P D Number of current residents: t _ Does residence have a garbage gender (yes or no): ,tZo Is laundry on a separatesewage system (yes or no): )C if yes separate inspection required] Laundry system inspecte&(yes or no): Seasonal use: (yes or no): N D Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): jVp Last date of occupancy: c r rc-1 COMMERCIAUINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): Rud Basis of design flow (seats/pelsons/sot eto: 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): GENERAL INFORMATION Pumping Records Source of information:L Y}s ► P o nce P u N K N o .. Al Was system pumped as part of the inspection (yes or no):tr 1 v If yes, volume pumped: Ballon — How was quantity pumped determined? Reason for pumping:. TYP F SYSTEM LAep is 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: Were sewage odors detected when arriving at the site (yes or no): /t/0 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: MCIA WARRANGER Owner. 59 WILLOW RIDGE ROAD Date of Inspection., NORTH ANDOVER, MA 01845 W M) z BUILDING SEWER (locate on site plan) Depth below grade: /0" . Materials of construction: ✓cast iron 40 PVC other (explain): Distance from private water supply well or suction line: X22 0'! Comments (on condition of joints, venting, evidence of leakage, etc.) - 'P (e tc.):'P(P�oKf Csoa� IN g►�+sE.y��ry SEPTIC TANK: _ (locate on site plan) Depth below grade: t-,_ Material of construction: concrete metal fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): _(attach a copy of certificate) Dimensions: / o L.> Sludge, Distance from top of sludge to bottom of outlet tee or baffle: / Z Scum thickness: ! Z Distance from top of scum to top of outlet tee or baffle: C- f Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: cis c> at c !� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7"ANIC .,vyif- caN� G2os5 V3ftflF�E int OIK1 coWD 2ec�nne v �7 IN, 1 0-t-Aj,>N p SLt-f go poc o.f[--j- GREASE TRAP:,v11"(locate on site plan). Depth below grade: _ Material of construction: concrete metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (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{ (,V r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS=E, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address TRICIA WARRANGER Owner. 59 WILLOW RIDGE ROAD Date of Inspection NORTH ANDOVER, MA 01845 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: gallonstday 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 openWocate on site plan) Depth of liquid level above outlet invert: t7 Comments (note if box is level and leakage into or out -of box, etc.): . distribution to outlets equal, any evidence of solids carryover, any evidence of PUMP CE AMBER:N d (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.): ti Few Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: TRICIA WARRANGER Owner: 59 WILLOW RIDGE ROAD Date of Inspection: NORTH ANDOVER, MA 01845 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why. .ape leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: Fi &c p overflow cesspool; number: innovativetalternative system Typelname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOIS: N 4 (tel 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: !f(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:, TRICIA WARRANGER Owner. 59 WILLOW RIDGE ROAD Date of Inspection: NORTH ANDOVER, MA 01845 yI3ja2- 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. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address - Owner. Date of Inspection SITE EXAM Slope Surface water Check cellar Shallow wells TRICIA WARRANGER 59 WILLOW RIDGE ROAD NORTH ANDOVER, MA 01845 ylaloz Estimated depth to ground water G3 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: b 9.7 4z, 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' h ground water elevation: his lG.� r. w halo a�- z ��-�.__ _1�c �se� c��✓J x o1��1 c'— iJS 50�v1 coKsyi.�G;.o� rn/��s I�D�cca�c toc> w,dvL Far Q N C J 3 D D LL m p lL p Q �y{ f4 V co w z ui c QC�co Q C7 croas W 9 tC (0 (D ccO o 00 N l --R 4i co C\l It ((O 44 2 �— N rl n r S �v U x 0 LL TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD �1 STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) U:a"I'E OF PUMPING; �J '�� QUANTITY PUMPED Ir� C'ALL0 C.I1)00L: NO YES SEPTIC TANK: NO YES �'.ATURE OF SERVICE: ROUTINE EMERGENCY OBS>FRVATIONS GOOD CONDITION FULL TO COVER HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE �j�HFR (EXPLAIN) C'UNI.1yI ENTS: �.UN"I'ENTS TIZANSFEIZIZED TO: 150.00• -- 59.97'`• 1Z7.05• _ 1 1 / L.OT 17 A -A L1Z7 ACZZ", u L. OT 1 �o la -A LOS,(,, J.CSC=S �Z4.15 • SO.O• i •• Ex15�G..o. 0.o LO, L.— Tra Id, L: G0(.7T . 144 41• Z-7.: L. G. o.Sa .O �•^ - t. Z39.4Z ) (5�1 W10E� -E: TNI7 OL>.,J OLIw4 4 QiV17 SON OC E NTI�t CO' QLV,7l1J DL1+l OC L4�0 Loc w+c0 J I�./Go G.ewtT aJCT,or+ Gs -,wt. �Cc1I✓sao l♦ �1WIK G. 4[Llu wl 4 A�9ot�wTG� oacrco OG.T0f8l2 4• IV7(p (t-LLP.O-T615). M PLAN OF LAND •I N NORTH ANDOVER. T=OQ- JAYCO CONSTRUCTION GOR -P> SCALE: I-- 40' SATE: AUGUST'?. 197T " 1 f.0 40 20 O 40 60 120 CQA"V- C. GELINAS E ASSOGtATES EN<jINEE2'J E AV-C1--11TEGTS 4S1 AN00VE2 ST., NO. ANOOVEQ,MA, of 11 I CEQTIGY T"ATI 14AVE C.ONQPOZMEO o+ scop WITH -rl4C QULEb AND QE.GULATIONSL OCTNE QEGlSTE2S OC DEE.OS IN P4EPARJNG; THIS PLAN. � e° ha fU11'rE� 01-11-77 r,-'.. • (:� DWG. NO Authentic Amish Furniture and Crafts Gazebos and Custom Buildings Garages and Arbors THE A1�1lISH TAADEA 120 Main St., Rte. 28, No. Reading, MA 01864 Office (978) 664-4462 Fax (978) 664-6829 A. GENE FRULL A FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *-W* * ****************"***APPLICANT FILLS OUT THIS SECTION* APPLICANT PHONE �I�IC'l�1Lr�� A>� �� LOCATION: Assessors Map Number PARCEL SUBDIVISION LOT (S) STREET ST. NUMBER G�//�� r` ��^��`� *-,.-►**.*********************`OFFICIAL USE ONLY*****-****`*" RECATIONS OF TOWN AGENTS: F StRVA-TION ADMINISTRATOR DATE APPROVED L) _ !( DATE REJECTED c COMMENTS TOWN PLANNER r COMMENTS FOOD INSPECTOR -HEALTH /jf/j SE.P-TIC I SPE OR-HEALT COMMENTS DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ ;. -�-_ PUBLIC WORKS - SEWER/WATER CONNECTIONS DRJVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE WELL DAT.ABASc ADDRESS: ACE OF 7,YTHLL WELL D. E? t FrT r p 4y : ,T: WELL LOCATION.: —'W-= PERLNT -7 DA ! E: DEPTH OF R j -,T- -=H CF VIEL L. a_ DRLLL ED DLT c U-Iv�'OFv-N - =E:0F WAtEF-A-RING ROCS WA=ANALY=DA -- -_ --_ Hr EMA. iGANESE: Y N' - ELGLIRON Y N 0 CONTLANMVAi=. yN --_ ADDRESS: Ix AGE OF W, r : 'WE=. DRILL: E war r. PERly 'I wEi.L LocA�rorr: WE'LL PFR. E i DATE: DEPT; OF WELL: TYPE OF W7 -LL: a.. DRILLED b. DUG° c. LFKNL 0WN TYPE OF WA ER BEA:=, G ROCK: r - WATER ANALYSIS DATE: .f' rEGH GA.NESL: Y N HIGH IRON: Y N OTHER CONTAIMINA TS: Y N 4 _ �; ;'♦1Ji�� rY��Mi'fi :��41 ��l .��'y �;��I,.?; LC1C•-9��r��, rlY�a ,. � .. ---- :�i'1.1'.;r: ;jLh:Y•� ;lli(�,)idi �ti^G1tl ti (` ��7iij7� Vr +/ {ll!1 ryy RT H'A PUNI �� , r >> > M U..Yrnl R a�,U04� SS SYTClF, �, ----- - I u Y' FIp;�'mNppIN� � � �)VANT17Y h�; „;, 1;U C.F ScR:Y C` r;0U Y �MERO_ 1�I'lky•11 1.C11� JAFP,LL' {ti �, I I +ly )N11+ %ri11C„`} Yy�/� lSrti.,{�! if•r Ij, ^i rl.,;t \kr `,-I',+�rii r __---- . ;' 1/.r f, �.I �' �I•VI )i•r� 1.�•.1,,,�'�{Tlr)!r ('s,lrY��,`�:�',��, ,' ,•' 1 �' �, � �, LI I, � [?; Ire , { �� rYI:Rr��i;�1�1� j �- -. Important: When filling out forms on the . computer, use only the tab key to move your cursor - do not use the return key. ommonwealth of Massachusetts City/Town., f NORTH ANDOVER MASSACHUSETTS Sy -stem' Pumping Record . Form 4 DEP has provided this form for use by local Boards of Health. The $yslop ng R cord mu; be submitted to the local Board of Health or other approving qty-, A. Facility Information 1. System Location: Address City/Town 2, System Owner: DEC 6 2006 TOb, OF t` ORTH ANDOVER v�'17-..- 'ic�ART State Zip Code Name Address (if different from location)___.._........_�._=_._�—•--------.._.. — — — — ---- --- - C ity/Town rumping Kecord �-11 Date.of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code Telephone Number -------' `- // Z� Date " 2• quantity Pumped: — Gallons Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 2<o 5. Condition of System: 6, SY em Pumped By: / /Ll/4-7 eA 1 ft'1w..Gw If yes, was it cleaned? ❑ Yes [- to Name Vehicle License Number — -- - Q �• Company 7. Location where contents were disposed: J Si ature of Hau - -- --_ Date ---- — http://www.mass.gov/dep/water/ proyals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of t IASSACHUSETTS - - ". i�1L L�'-�{l�y.�i,gip+:Rfr,7.1'L.�,L(�::,r'.fi:): t ..t:G'PS�L"•��15./'�'�'. ., '. _ . DEP..has WWded thh form•for use by local kcards of Health.' The Sys em Pumping Record must be submitted to ttte.(ocal'6oard of Health or other a PProving authority, A; FaC111tY Inform tion V 0 LOU, Un ,portmt: > ,; ; 1 J7AL f '.'DOVER9 Out 1. SystemLocation;Lir . R i f r:E. NT • :i•`y'COrtlput8r, tlte," � '� only the tab key Address to move your:;!`L%• ��/��-�i •, ,.auxor • do �Ot ' usi the. retum•:'VClty/Town State ZIP Code :.1-rYrl• iii; ,• ';Zfr.Sys e e °.:r`:'• , { . ••�.., �;4�f �,: �14r.!:1 .i't's. .'/l. Y:� .n.r,�: v Name ;,::• 1, ;, ,:.:,, .,.:; . ;v- Address (if different from location) ------------ CitylToum, r: State' Telephone Number -v�ic � i':i<}'�r�i,Il.•;�Y fi (i<r,.aP,b��ll'.L,r.+�'•,, '... .. ,r DatQ'of Pumping Date 2. Quantity Pumped. Gallons 'Typ@ pf.system: , ❑ Cesspool(s)k1eptIc Tank ❑Tight Tank Other (describe)r 4,v"Effluent lee Filter present?.❑ Yes o If yes was It cleaned? ❑ '. ; Yes ❑ No t•... , .� ..•r : �:. >.'/.ir=:"'•';•L+ CO�dlt)0 ` St t17',.y:;. ,•,;.• .. .. Wit.' •'r Iti(':y.' .. .. ti✓V t:i�:'' Y•.•: .1 � ::�-. y:•; .{, .v i.i'. �i 'lei: '1 rl�.,.,,,;�1:' ir„ ',.•i ,.f• !}r''.. i'. L' r��'�•'•' 1. /ia,•� ,i y, 1•'.'S•. :,i, {f� : 1•i.',4! (, ft l.1'"•1'•.,: _. S Pumped By:'" •i•-•�%..' :��'i•+-' :•."L,'•.i;;1�r ante•:\'��.�^:''. .1'. ..,�Y�` L�� _ .::� ., ,':'�'• ;a :�Ar'a;�;.;•f;^4 <�,i:fq' ,rnll 1 J ,11i �: .�r `(' c 11 Ne t� f.�` C � lite J•�•: -... �'1'' ��:VT. •� can a Number :4�y:.�7,:.'.»'�.r4;`;K`rhv;�.��}�t'��7f� �4�Cwt.' ��:rc •1 ii +<: : ,�,^. - ♦:)�'Ij• %: ,�'t� is �.yf:: r. ;vf.N'•Y rf•,++ �.jL' f: li 1 1•./,. . •• ` .5,; i;�.,, :1 :••y-' ire +p;. f$� 1'S''r.�' ��'• { r('i' .J::':: .. ,,', � .. . IU•' LS;d• , A t�'rjyl t, ;M�J Fr. Y�/�,1.,.►i!li'•.,.... :✓•.:. y;� !''.` :T:.Y.I'rSj'., t'�,:i '..ry,•�••'y'r1$�'. 7i�1+f'rJ�t.'a:r., ��L�' �#.':.:f ./ LoCatlon.where contents were,dloposed; �; ;�� ; r.::• cry • •'L,�.�.1:. ^t i"�'".r.�.� �.�; ,: �'�.'1�'' til •, �' � � _ / . z ;i;••rpt:: a%. �` i�4:� .'.3,`':'. •i l;��'.• /V/`/y/✓/,J1/ • _J :�. `'L,;Li '.;1 jib .. •y '�lr'1'�i..�,:; `•, ', f; r'+M��L'• 1•�'.;(:".�Y., i1 ..'�•� /': �'•i.'' � .j 1.1 .,.:•� {•�.• ,fair, ,J. ;,._.;:`'• .�; X31.,...•. c•c: ,i;.:.':;:, �•t:. + I;.;.:r•:•.' 1, . ,. d •.,;: .=r..,i_>•;;:.i;�':;�;•r: :•.:•.'.; � 01 , r::;•��,.:;,;-;.,!, .,,..•.:.1....: Date http://www,masargov/dep/water/approvi)s/t5forms,htm#Inspect • � tStonM.doa•08I03 :::•. System Pumping Record Page 1 of i E�:• MASS�C.HU.SS \ �t�rl��jwjt(t`riirG)I,i1�,�',r,!'��•,Y��)il',.��, ... QeP,h�i P/pYldfd Ihllylprrn for �,o lo.cct Goer �1 I'./bt1t1111Od 1p V1► IOC 11 8clrcr c'r �o , A, Facll-ry In�.orm��lon 01 ,•a '41, ,s r ' • yw vr- �;.SYlem Owner,`,.',r,.;'... C`'' i,i'''Y'4/�.rlL''�1:'h►,''.i' 77 '''' d Illnl ran buVonl Cq! o,n i61P,umAI ng, �, Q,gwd, Ll � Oale of Pumpinp ' �' .'"' i r . • � 111 Other MI, ' IjonR n ,,y i,,�;;�' rr,..,/�!',Tt, ,;,,(�Ij,, r!)� l�r1s'i••''i' , . , .. ., , r� ,•lQ!�'y9 0 'sYl��,ml'rYt, :'�„ti'iii''r,�'Ily.t!''J%�/'r,�'h;1r,VjvJa�' CYr,"�'�•' ' ', ,'•Yi;',•r'''I,�'Iryl'i'''' "Iii,' 5�I� ito',II;Iy9.Py�mped If. ID`S',• ,��l,rlr,`,., i��ll�i�'t �li� �l�{�'�,1�;'' . POher� 400lin�i koro dopc • ,, %,'� v l ''r1 r ►"r it �i V 'r I{(9� 1.v AIVI ma �, porldaplvlift lappoyija worms r'm,ai :4� t'i77npn, ri,mp„ 6puc Ten, Yp� II y6t. „•et 1, c�vaneo� ', r►/ /:'., 3 . Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 GSM y` A " [!OV 21 2012 TOWN OF NC: t: H ANDOVER HEALTH CZPART%;,_NT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. City/Town Ma State State Telephone Number 01845 Zip Code Zip Code B. Pumping Record 1. Date of Pumping lol 100o p g Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By ' ra n / A Name Stewart's Septic Service Company 7. Location where contents were disposed: Signqture of Hauler na ure of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 0 So. Mill Bradford. Ma 01835 Date Date / t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms on the computer, 1. System Location: F I IlJ1�.1� use only the tab key to move your Address cursor - do not North Andover use the return key. City/Town 2. System Owne 1 t . Name retwn Address (if different from location) City/Town Ma State State Telephone Number 01845 Zip Code Zip Code B. Pumping Record 1. Date of Pumping lol 100o p g Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By ' ra n / A Name Stewart's Septic Service Company 7. Location where contents were disposed: Signqture of Hauler na ure of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 0 So. Mill Bradford. Ma 01835 Date Date / t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 ,,. TO: NORTH ANDOVER, MASS X 0 X 04 54 19 77 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This 'is to certify that I have inspected the construction of the said disposal system at 2o7- bollo-tu R/ GCGE North Andover, Mass. SITE LOCATION The r and construction are as specified in my plans and specifications dated SETTS 19 ll G� (nL ;111 O ,g. Pr cf. eer/R*g.� F ��°W400 e% SOIL PROFILE & PERCOLATION TEST DATA -• moi -- ��Xyw/a-"'a) �Z- A� Town/City No.&St/reetLot% No. Loc./Subdiv. %�Uc,J �'.l e Plan Owner "'O"It Investigator //3 6LgC .1ld Observer Elev. 0 1 2 3 4 5 SOIL PROFILES -DATE 3' Elev. 3' Elev. � 0 2 3 4 5 1 2 31 4 5 4'Elev. V 7 7 7 �lC� 8 8 8 9 9 9 10 10 10 Benchmark Location Elevation Da.tum Percolation Tests -Date Pit Number 1 2 3 4 5 Start_ Saturation Soa'c-Mins . Start Test -Time Dro of 3" -Time Drop of 6" -Time Mins.lst 3"Dro Mins.2nd 3"Dro Notes & Sketches on Back Frank C. Gelinas & Associates, North And. a - m z. _tic/✓��r-_ I /.'z.9v T= /3 Z. 6 6- N p. Ow v w "A ., nil 2 2 3 rh � y N p. Ow v w "A ., nil rh A, I tai � y � zb p Do m 0 it C� o ' o n Cl) y o n � � y � 0 y O m y A, I tai m m � zb p Do Zo�