HomeMy WebLinkAboutMiscellaneous - 61 CARLTON LANE 4/30/2018 61 CARLTON LANE
210/106,9-0000.0
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
I� SV�y
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
�O N OF NORTH ANDOL'�R%
Property Address:_61 Carlton Lane BOARD OF NFAI.TH
_North Andover
Owner's Name:_Michael Philpott
Owner's Address:_61 Carlton Lane_ 10152002
_North Andover,Ma.01845_
Date of Inspection:3113/2002_
Name of Inspector: Neil J.Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road—
_Andover,Ma.01810_
Telephone Number: (978)475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of 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:
_X Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
' s
0
Inspector's Signature: Date: _3/13/2002_
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:After installing new outlet tee with gas baffle in septic tank&cutting down vegetation
over each system,septic system now passes Title 5 Inspection.
****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.
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
h
t
O
Oq SveV
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_61 Carlton Lane
_North Andover_
Owner's Name:_Michael Philpott
Owner's Address: 61 Carlton Lane_
North Andover,Ma.01845_
Date of Inspection:_2/26/2002_
Name of Inspector: Neil J.Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)4754786_
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:
Passes
_X Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: _2/26/2002_
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. 'tUM14 OF NORTH AWDO
BOARD OF HFA!+'a
Notes and Comments:Needs outlet tee in septic tank&vegetation cut down over leach trInches. w
MAR — 4
d '
L — —
****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: 61 Carlton Lane_
_North Andover—
Owner: Philpott
Date of Inspection: 2/26/2002_
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:
B. System Conditionally Passes:
_X One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Needs outlet tee in septic tank.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
_N_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:
_N_ 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 box. 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:
_N_ 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: 61 Carlton Lane_
North Andover—
Owner: Philpott
Date of Inspection:_2/26/2002
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
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 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.
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: 61 Carlton Lane_
North Andover
Owner: Philpott
Date of Inspection: 2/26/2002_
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or`�no"to each of the following for all inspections:
Yes No
No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow
_No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_No Any portion of the SAS,cesspool or privy is below high ground water elevation.
No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
No_ 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.]
No_(Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ — the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 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.
Page 5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_61 Carlton Lane
_North Andover_
Owner: Philpott
Date of Inspection: 2/26/2002_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
Yes_ _ Has the system received normal flows in the previous two week period?
No_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Yes_ _ Was the facility or dwelling inspected for signs of sewage back up?
_Yes _ Was the site inspected for signs of break out?
Yes Were all system components,excluding the SAS,located on site?
_Yes_ _ 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?
_Yes_ _ 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:
Yes no
_Yes_ _ Existing information.For example,a plan at the Board of Health.
No 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
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_61 Carlton Lane_
North Andover_
Owner: Philpott
Date of Inspection: 2/26/2002_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_ Number of bedrooms(actual):_4—
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_600_
Number of current residents:_2_
Does residence have a garbage grinder(yes or no):_No
Is laundry on a separate sewage system(yes or no):_No_ [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):_No_
Water meter readings:_Aug 99 to Aug 01=41,000 Fe x 7.5=307,500 Gats./730 Days=421 Gals./Day_
Sump pump(yes or no):_No *Has sprinlder system
Last date of occupancy:_Current
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
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:_Pumped Nov.01,owner
Was system pumped as part of the inspection(yes or no):_No
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 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:_16 years old.11/8/1986.
As per info at B.O.H._
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Carlton Lane
North Andover
Owner: Philpott
Date of Inspection:_2/2612002
BUILDING SEWER(locate on site plan)X
Depth below grade:_24"
Materials of construction:—X—cast iron _X_40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):_4 K cast iron thru wall.3"PVC in house.
No leaks.
SEPTIC TANK:_X locate on site plan)
Depth below grade:_12"
Material of construction:—X—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: 10'x 5'x 4'
Sludge depth 1"
Distance from top of sludge to bottom of outlet tee or baffle:_N/A
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle:_N/A N/A=outlet tee off in septic tank.
Distance from bottom of scum to bottom of outlet tee or baffle N/A
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.):_Inlet tee ok.Outlet tee corroded oft;needs replaced.Depth
of liquid at outlet invert.No evidence of leakage._
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
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
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Carlton Lane
_North Andover—
Owner: Philpott
Date of Inspection:_2/26/2002
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:_X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_0
Comments(note if box is level and distributio_n to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):_D-box level&distribution equal.No evidence of leakage.evidence of
carryover.
PUMP CHAMBER: (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.):
Page 9 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Carlton Lane_
_North Andover—
Owner: Philpott
Date of Inspection: 2/26/2002
SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_X leaching trenches,number,length:_4 trenches 50'long_
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,
etc.):_Soil ok.Vegetation needs to be cut down,small trees&brush growing over trenches.No sign of
ponding to surface._
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 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.):
r Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_61 Carlton Lane_
—North Andover
Owner: Philpott
Date of Inspection: 2/26/2002_
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.
Venti
p Pe
in front —� D-Box
of d-box
2
1
50' ♦ O
O
I O
C A to 1=62'9"
Ato2=66' A
Bto1=68'9"
Porch
B to 2=72'1"
Unable to get measurements to d- Driveway B House
box,located to far from house.D-
box located directly in front of vent Water
pipe. Meter,
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_61 Carlton Lane_
_North Andover_
Owner: Philpott
Date of Inspection:_2/26/2002_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 4 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record-If checked,date of design plan reviewed:_3/3/1981_
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:_As per design plan_
Tel: (978)475-4786
Fax: (978)475-5451
BATESON ENTERPRISES, INC.
Excavating-Water.&Sewer Lines-Septic Systems&Pumping Service
111 Argilla Road Andover,Mass. 01810
Title 5 Inspection Report
Property Address: 61 Carlton Lane, North Andover
Owner: Philpott
Date of Inspection: 2/26/2002
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations,and I hereby disclaim any further
operation of your current septic system.
Neil J.BaWson
Bateson Enterprises,Inc.
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TO: NORTH ANDOVER, MASS. 19 S Z
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the construct io materials of
said disposal system at _,�-� 7�A I
Site Location
North Andover, Mass . �,�SH OF
RICHARD Gw
The grades and constru tion materia re cTS s fieri in my plans and
MINSKI w
specifications dated , 9 o s uilt
o �
Reg Prof.En 'Reg. Sanitarian
• e
t) AAA,
GRAH31R `
` l?iK1MAX
Board of -Health aLPTIC SYSTEM
Ank_a Kass•
INSTALUTICK CHECK LISP LOT
CNID DATE DISUPROVED RCAVATIOId OK FAIL
� easonst "
FAIL OK MA/8
1. Distance To s l�lo' XO
a. Wetlands
b. Drains
c. Well Ta Ax-cr
�i l�� 7TZE ✓
2. Water Line Location
3• No PPC Pipe
4. Septic Tank—
a. Tees -_Length & To Clean Out Covers.
-
b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box4,1
a. Covers & Box - No Cracks _ a
b. All Lines Flooring 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. Di mans ns
b. Sto Depth
c. ash Pads
d. ess
e Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal 7P ": '6
9. Final trading Inspection
10. Barricading Covered System
ll. As Built Submitted — -?i Pew _
a. Lot Location W
b. Dimensions of System
c. Location with Regard-to Perc Test
d. Elevations
e.' Water Table
IIS
Oyr Kcal h
FSa�.xB
A SUBSUFFACE DISPOSAL DMO CHMK List
LOT W
APPROVED DATE_ DISAPPROVED DATE
Provided: Reasons:
f!'p4Z/eZ
Title V FAILCr
Reg 2.5 The submitted plan must show as a niniMUm:
the lot to be served-area,dimensions lot #,abutters
location and log deep observation holes-distance to ties
c location and results percolation tests-distance to ties
design calculations & calculations showing required leaching area
location and dimensions of system-including reserve area
existing and proposed contours
g location any wet areas within 100' of sewage disposal system or
sclaimer-check wetlands mapping
) surface and subsurface drains within 1001 of sewage disposal
stem or disclaimer
i) location any drainage easements -.thin 100' of sewage disposal
system or disclaimer-Planning Board files
known sources of water supply within 2001 of sewage disposal o
system or disclaimer
location of aay proposed well to serve lot-1001 from leaching faci2it,
1 cation of water lines on property-101 from leaching facility
�(-mj location of benchmark
n driveways
arbage disposals
no PVC -to be used in construction
q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
ko" Otter elevations
r maximum ground water elevation in area sewage disposal system
s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
a) capacities-150% of flow, tater table, tees, depth of tees,
access, pumping
(b) cleanout
10t from cellar wall or inground sulmning pool
25+ from subsurface drains
Reg 10.2Distribution Boxes
(a) Wo-pe greater than 0.08
Reg 10.1 b) sump
M `
Mird-of Health
North Andover^si
SUBSURFACE DISPOSAL DESIGN CHECK-LIST
LOT # ��
APPROM DATE.5--�� fid`., DISAPPROVED DATE-____„
Provided: Reasons
� N
Title V FAIL 09
Reg 2.5 The submitted plan must show as a udnimum:
✓ a) the lot to be served-area,dimensions lot # abutters
b location and log deep observation Mes-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
✓ e) location and dimensions of system-including reserve area
f) existing and proposed contours
g) location any wet areas Within 1001 of sewage disposal system or
disclaimer-check wetlands mapping
h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any drainage easements within 100' of sevage disposal
system or'disclaimer-Planning Board files
(3)_ known sources of vater supply Within 2001 of semge disposal a
system or disclaimer
(k) location of auy proposed well to serve lot-1001 from leaching facility
(I) location of water lines on property-101 from leaching facility
c/(m) location of benchmark
7(n) driveways
(o) garbage disposals
no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Otter elevations
(r) mmaum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
(a) capacities-150$ of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimming pool -
(d) 25+ from subsurface drains
Reg 10.2 7Distribution Boxes
;b)
a) pe greater 0.08
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4240
Date..�.�.. 3 .�..
NORTH
°f<«'° '•'"a TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACNUSE�
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This certifies that ......!...�.�.........;1..�.`A.......�...t- Gr .!�...... .......
has permission to perform ...... . `� `
.e..� d............ ..................................
wiring in the building of........................ ......................�1�......................
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'►ndover S.., .�....� -
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Fee. . .. Lic.No.,.<-... .�. f...................... ...�..... . ................
EL - RICALINSP CTOR
Check # J
Official Use Only
THE COMMONWEALTH OF MASSACHUSETTS Permit No.
7r— I )
Department of Public Safety
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy&Fee Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:007
(Please Print in ink ortype all information)
To the Inspector of Wires:
Town of North Andover
The undersigned applies for a_permit to perform the electrical
ect—ricalwork described below.
Location(Street&Number6/ — Cno MONS\ e
I
Owner or Tenant /a \I 's / 1ft/"N1
Owners Address 1579M055—
Is
5/ 055—Is
this permit in conjunction with a building permit r�/Yes No (Check Appropriate Box)
A 1� /"
Purpose of Building k _ Utility Authorization No.
Existing Service Amps Voits Overhead • Undgrnd No.of Meters
New Service Amps Voits Overhead • Undgrnd No.of Meters
r,
Number of Feeders and Ampaciry
t
r
Location and Nature of Proposed Electrical Work ic,�n1 1 EXr�?7rNrr C'�, � R
2-WP,LL LT,S(f,0NS?,5/-, y—keces56 L-rs,
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers 'KVA
Above In
No.of Lighting Fixtures Swimming Pool gmd grnd Generators "` KVA
No.of Emergency Lighting_ "
No.of Receptacles Outlets No.of Oil Burners Battery Units
No:G-1 Switch Outlets No of Gas Burners FIRE ALARMS No.of Zane
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices _
Heat Total Total _
No�of Di sal No. Pumps Tons KW No.of Sounding Devices
No./of Self Contained
No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices
• Municipal • Other
No.of Dryers Heating Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters KW Signs Bailases Wiring
No.Hydro Massa a Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO =
have submitted valid proof of same to the Office YES= NO = If you have checked YES le se indicate th'typ�f coverage by checking the appropriate box.
INSURA E = BOND = OTHER = (Please Specify) _ _—5,- —
�/ (Expiration Date)
Estimated Value of EI ical Work$
Work to Start ��_ Inspection Date Resquested_ _Rough _Final
Signed under the Penalties of perjury:
FIRM NAME LIC.NO.es 30 Ll V
Licensee t _Signature r LIC.NO. �
c'�! p I //� r��,�� 41d_O� Bus.Tel No._ < <' r
Address! TIR-5
—W/AVIV 3� i/�•ld�Lr r Ir7r -v�Att Tel.No. — Q 7_407V
OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent.as required by.Massachusetts_...
General Laws.And that my signature on this permit application waives this requirement. Owner Agent(Please Check one)
Telephone No. PERMIT FEE$
(Signature of Owner or Agent)
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Commonwealth of Massachusetts
assachusetts
System Pumping Record
System Owner System Location
g7,AA
Date of Pumping: a Quantity Pumped: ��gallons
Cesspool: No f��f Yes [I Septic Tank: No [] Yes [�}�
System Pumped by: V4&4" 460&*aided License#
Contents transferred to: Greater Lawrence Sanitary District
Date: -Inspector:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example: left front of ouse)
� tC �
DATE OF PUMPING: Ur �UANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YE_S.
BON
NATURE OF SERVICE: ROUTINE EMERGENCY v 3 Q no
NO
OBSERVATIONS: --
GOOD CONDITION FULL TO COVER'-
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING .RECORD
SYSTE.NI OWNER & ADDRESS _ SYSTEM LOCATION
(example: left front of house)
llA`IT OF PUMPING: 5'01-V QUANTITY PUMPED. L,�20Q GALLONS
CI'SSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE X EMERGENCY
_ OBSERVATIONS:
GOOD CONDI`T'ION �_ FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
5'i'STE N'1 PUMPED BY:
CONI MENTS:
CONTENTS TRANSFERRED TO:
AddressAl--fC -0-Z:: �/ , G,/V Title of File
Page of
Date File Open: Gate file closed:
Doc Document/Action Title
action Date of Refer to other Purpose of Document/Action and notes
Document/ docurnent/
IWum• Action Department
Board of Appeals — Board of Health Planning.Board _ Conservation Commission — B—dflding Department