The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 625 BOXFORD STREET 4/30/2018 (2) 625 BOWORD STREET 210/105.0-0053-000D.0 ( c r r 1 � � V , r r � v �r l 625 BOXFORD STREET 210/105.C-0053-0000.0 - • N ' °f � Commonwealth of Massachusetts Map-Block-Lot -�^�° `�• 105.00053 BOARD OF HEALTH Permit No North Andover BHP-2013-0997 ----------------------- FEE ---- -------------- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John J. Soucy - ------ - --------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. b—6 Dx at No STREET --625------BOXFORD-------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. 13HP-20137099 Dated October 24,2013 Issued On: Oct-24-2013 BOARD OF HEALTH ----------------- ---------------------- - 10 1?� ............................................................................................................................................................................ 625 BOXFORD STREET Reference No: BHJ-2013-000077 ................................... Permit No: BHP-2013-0997 Department: ................................... North Andover BOARD OF HEALTH ......................................................................................... Account No'. 1001001.1.5.0510.00 Fee Type: ................................... DWC-Component Repair PERMIT Receipt No: REC-2014-000499 ......................................................................................... Paid By: Paid in Full On: Thu Oct 24,2013 ................................... John J. Soucy ......................................................................................... Check No: 26212 ................................... Received By: Lisa Blackburn ......................................................................................... CUSTOMER'S COPY Amount: $125.00 ...................................................................................................................................... .......... 6668 , ' L9 Town of North Andover HEALTH DEPARTMENT ,SSACNUS�� CHECK#: 3 LOCATI a� H/O NA CONTRACTOR NAME: l Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report x 0, $ ❑ Other. (Indicate) $ Yb Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ,t r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is North Andover MA 018_54 10/31/13 required for every — - _ _-- page. City/Town 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 on the computer, use only the tab 1. Inspector: p� r key to move your p cursor-do not John J. Soucy use the return Name of Inspector HEALTH( r�'`�ANDDyER key. QEPARTMENT Soucy's Sewer Service, Inc. rob Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 _ 13397 Telephone Number License Number B. Certification 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 ❑ INurther Evaluation by the Local Approving Authority � 10/31/13 speature Date The ystem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 nl Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <°wM 625 Boxford Street Property Address David Chiasson _ Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 — — - page. City/Town 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 2 of 17 I i ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. City/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. B) System Conditionally Passes (cont.): ❑ 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 ❑ 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): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i 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 ❑ ® 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 '/z day flow 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 , i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 625 Boxford Street Property Address David Chiasson _ Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. Cityfrown 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 NIA) ® ❑ 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 or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 c ' Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is _ MA 01854 10/31/13 required for every North Andover q City/Town State Zip Code Date of Inspection page. D. System Information Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No well Water meter readings, if available(last 2 years usage(gpd)): Detail: See Attached Sump pump? ❑ Yes ® No Current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 official Inspection Form.Subsurface Sewage Disposal system•Page 7 of 17 t5ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10131/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current Date Other(describe below): General Information Pumping Records: Source of information: Soucy's Sewer Service Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? gauge on truck Reason for pumping: Maintenance and Inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 16" Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 100' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below rade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form a4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.0 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is North Andover page. MA 01854 10131/13 required for every City/Town State Zip Code Date of Inspection D. System Information (cont.) i Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 38" _ Scum thickness Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 14" Tape and sludge tool 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.): Pump tank every year Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3/13 Title 5 Official Inspection FormSubsurface Sewage Disposal System•Page 10 of 17 Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is North Andover MA 01854 10/31/13 required for every -- - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is North Andover MA 01854 10/31/13 required for every __ _. __ page. City/Town 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 0" 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.): "Ylbox replaced and inspected prior to Title 5 inspection, see permits. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 X Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 50' ❑ 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.): No signs of ponding Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1 �r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® h hand-sketchin.t erea below a drawing attached separately 6J0 a t5ins•3/13 Title 5 Official Inspection Fonn:�Subsurlace Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °wM 625 Boxford Street Property Address David Chiasson Owner Owner's Name information is required for every North Andover MA 01854 10/31/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: T @ S.A.S 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: No plans on file Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Dug hole with auger in rear, low drop off area, .5'water table, adjust elevation difference from rear to front 5+feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 /t " Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 625 Boxford Street _ Property Address David Chiasson Owner Owner's Name information is required for every North Andover _ _ MA 01854 10/31/13 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 ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r _...._ - _ ._. _ - _. _... .. w T1 01 Commonwealth of Massachusetts 105-CO053 BOARD OF HEALTH Permit Ni North Andover BHP-2013-0997 5125.00 ........ . ... DISPOSAL WORKS CONSTRUCTION PERMIT Pennission is heref)v<tiranted John J. Soucv to(Repair)an Individual Suwale Drspo al SvStrrn. � 1t No 625 BOX170R.D STREET as shown on the application for I?isposal Works Construction Permit No. BHP-2013-099 Dated October 24.20 i Isst,c,I 011_Oct-24-20i =�s '` BOnitD OF -l]~ ..� f i COMPLETE SEWER-SEPTIC SERVICE — DATE Of SER ICE INVOICE /0 78 N. Broadway(Rt. 28), Salem, NH 03079 CUSTOMER NAME Serving MA & NH BILLING ADDRESS 800-541 -9379 CITI' /I STATE 21P PHONE: 9/ 1 Come visit us at JOB ADDRESS IF DIFFERENT THAN BILLING ADDRESS ADDRESS [D=E =RIPTIONIOF TATE ZIP www.soucysewer.com WORK 41 Ll 4aic2 C' VACUUM PUMP ❑ SEPTIC TANK GALS. ❑ CESSPOOL ❑ OVERALL SYSTEM ❑ DRYWELL ❑ BASEMENT ❑ FAILED SYSTEM COMMENTS TERMS OF PAYMENT TYPE OF SERVICE TAX EXEMPT CASH ❑ RES/COMM❑ TAX INDUSTRIAL❑ /, CHECK ❑ CHARGE ❑ PLUMBING❑ TOTAL $ u JOB COMPLETION This is to acknowledge completion of the above work which has been done to my satisfaction.We will assume no responsibility for any damage made to sprinkler, lawn, bush, driveway, curb or walkway.Any form of payment provided by the customer constitutes a binding signature of this invoice and assumes all responsibility for payment in full,along with any collection or reasonable attorney fees on outstanding balances. DATE CUSTOMER SIGNATURE SERVICEMAN'S NAME w ,5wDr • Commonwealth of Massachusetts Map-Block-Lot 105.00053 ----------------------- BOARD OF HEALTH Permit No x; North Andover BHP-2013-0997 P.I. � FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John J._Soucy----------------------------------------- _ ________ _ _ _ ________________ to(Repair)an Individual Sewage Disposal System. D—F)o k. [ELL.JCopy at No 625 BOXFORD STREET as shown on the application for Disposal Works Construction Permit No. BHP-20137099 Dated October 24,2013 Issued On: Oct-24-2013 BOARD OF HEALTH %r........................................................................................................................................................................... 625 BOXFORD STREET Reference No: BHJ-2013-000077 ................................... Permit No: BHP-2013-0997 Department: ................................... North Andover BOARD OF HEALTH ... ..................................................................................... Account No: 1001001.1.5.0510.00 FeeType: .................................... DWC-Component Repair PERMIT Receipt No: REC-2014-000499 .................................... ......................................................................................... Paid By: Paid in Full On: Thu Oct 24,2013 .................................... John J. Soucy ......................................................................................... Check No: 26212 Received By: .................................... Lisa Blackburn ......................................................................................... DEPARTMENT'S COPY Amount: $125.00 ........................... L...........................................................................................................................................................................j Application for Septic Disposal System /0/' -1/1z s •`" ••a o 3 onstruction Permit —TOWN OF TODAY' DATE t i $250.00—Full Repair " �90:,�;0•:ray" ORTH ANDOVER, MA 01845 $125.00-Component V, �SsACIN, Important: AoMication is hereby made fora permit to: When filling out Construct a new on-site sewage disposal system* forms on the computer,use ❑ pair or replace an existing onsite sewage disposal system* only the tab key to move your Repair or replace an existing system component—What? 90 X27 cursor-do not use the return key. A. Facility Info /�tion ISI Address or Lot 1v 600 _,_&14- - City/Town 2.-*TYPE OF SEPTIC SYSTEM*: OCT L 4 2013 ❑Pump Gravity(choose one) ***If pump system,attach copy of electrical permit to application*** TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Conventional System(pipe and stone system)- (3 Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner Information V(!� C�I�S ivin Name 6 a.7 ao Address(if diiferen�m above) Al wi"91% n r Ss-q Ckyfrown State Zip Code Telephone Number 3. Installer Information �+ Lr v Kt _ kG�f m J e.d-z c th Name Name of ComAny 22 Address Cityrrown State Zip Code 603 ---?/ 7!S' Telephone Number(Coll Phone#ff possible piease) a. Desi ner Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Application for Septic Disposal System 10, i TOD Y' D T `Construction Permit TOWN OF ORTH ANDOVER, MA 01845 $250.00—Full Repair 39s�5 $125.00-Components SsAcNus� PAGE.2 OF 2 A. Facility Information.continued.... s. Type of Building:JZIResidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the atom-described on-site sewage disposal system in accordance with the provisions of eTitle 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North An ver,and not to place the system in operation until a Certificate of Compliance has been i77by this Boar fHealth. D N#fe Date Applicata Approve y:(Board of Health Representative) 3 Name; � Date A licatlon bi�approv for the following reasons: For Office Use Only: L Fee Attached. Yes No Z. Ptojcct Manager Ohllga 'on Form Attached. Yes_ No 3. X'umn Svstem? Ifso, i 1 i Yes _ No 4. Foundation As Bud t?(hew c7p . on ronly): Yes_ No_ (Same scale as apptov5. Floor Plans?(hew construc : Yes No Application for Disposal System Construction Permit-Page 2 of 2 • S��I,Bbry6q' North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 625 Boxford St. MAP: 105.0 LOT: 0053 INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box 10/3012013 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPEC ION: �3 SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Buildin sewer in continuous grade, on compac d firm base ❑ Cleanout per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole pita ❑ 1500 gallon en installed H-10 loadin ❑ Monolithic ta ❑ Water tightnhas been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade in tailed over one access port ❑ Hy& ulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank ole has 6" stone base ❑ Weep hole plug d ❑ 1500 gallon Pum Chamber installed ❑ H-10 loading ❑ Monolithic tank constr ction ❑ Inlet tee installed, cente d under access port ❑ Pump(s) installed on stab base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade install over pump access port ❑ Water tightness of tank has been a ieved by testing ❑ Hydraulic cement around inlet & outle Comments: CONTROL PANEL ❑ Alarm & Pum are on separate circuits ❑ Alarm sounds uVhen float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box ❑ Inlet tee (if pumped or>0.08'/foot) []Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 10/30/2013 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D-Box By: John Soucy At: 625 Boxford Street Map 105.0 Lot 0053 North Andover, MA 01845 The Issu ce of this c ificate shall not be construed as a guarantee that the system will function satisfactorily. s Sawy r Publie H lth ren 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com G-�/U3/1771 UG: J I CWHM I JHI IOU V CR fHVC VJ A1.6 AN 13.6. 4, 1�!/e� STS"T Swrlc TM sMWIcg 1JU' [yin Sf 47 MIJAW erpmr A/a rlq MADPM, Mh 01835 amu! L 978-372-7471 mom OF a � Him Y Repaw FOR TCWN CF SVD lyn/per' ADMESS Isoo -54 ✓� ' 5q DSGaor, , /ovo ✓ � 17d� 4/ym�� lane ✓ /907 S�le,•,-t Sf- ka,% !d lano !dao fiWn 6Gn e r - 103 zdl 1550 6d0 ✓�"�� 1u �btsrbn d� lei 1�' address t5-/ n u. �a2 �� Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes -- o action :1Document/ document/ Num. Action Department Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department r F tJ ✓� I ( H I ! Jl � r 1 : ( .,.,yln yy f' Sri rr i' f1' 1'�r�11�r 9}v yy� SSI.tr�r I�}' + •. �� r1l�1'>+i� '�� Fr Iraa�l ru 1 S1/��rlP !, r.,r� � 7r ✓ ,, s f A "7'b�YN OF NO RTrAaOVR; SYSTFM PCJMP1.N C RA Oq A0DRS✓ S SYSTC 0TO -- ` ��ah. (ezam�le�lc�fi(roni of �n (zix ,y ', �. ,i Sp' � � Ilsf Iryr ,� , �, .,,,. •' U I, C UF:PVMJ��N�, X p3 Q.VANTITY f'UMPCD ''/ ✓1 .�.�:YriuN! ,ik,ytd l lrl' 1.t l r i �,�I'UOL. 'N0 YlrS, SEPTIC TANK; N0 Y — �TURE 0FSERVICEr ROUTINE EMERCEt�CY V OUS RY,IT0 N ;,' CU11:UU4'C, N�,U11'IrON h'ULL TU COYck. - l3aFFLLS IN I)L,ACP L:EACHFIC, LD RVNUAC?C,.. CX CESSI�.YE �O.L1DS :. F!✓O:O.DED'. --_ r 5041QVC ARCiYOYR O�HFR (EXUTA.iN) r rf{ r✓� rs dnr�lvf °. ��I,�r� f i` r` i Is/ f::.r I r;Ji✓✓ 11'+�'rr1$t+ti)f,lr%v�C+'�) 5-1 `I �{{ p ! ;:iY 4iv rlr r", •.I i ! r.d�n'` ti;yr4 i1r�4rt';f;✓yrlss,. r 1, , � �� I l M PUMr `Iti 3Yr i cu�If�IrNTS , i I u� I �i�^I rs' 7��Z�NSrclii�l,r�D �rv� TOWN OF NORTH AN' VEP, SYSTEM PUMPINQ R CON 0 6 2005 u�rt �o� (Q D � ;vaR SYSTEM 01, N!~Rdt AnQRBSS - T�' ,cmT SYSTEM 1; kTloN=------- GV7 tit DATE OF PUWNq;�� .p UANTIT �..._Q Y PUMPED:. tSSPOOL: NO �V;;, ..... .. Sopcic Tank: NU YES (/ NA rukE op SERVICE: Kou'rINE„��R��r,c� 011SERVA'I'IONS: GOOD CONDITION ULl.'ro COVER HEAVY ORBASE _ BAFFLES IN PLACE, ROOT'S L6ACHFIELQ RUNBACK 6�fC&48YYE SOLIDS FLOODED . OLID CARRYOVER,_,_.OTHER EXPLAIN Sy.tvm PWRPC4 by rrra. VUMMENTS. WN I'LNTS rKANSr'EKKbD 1*0 �L\ Commonwealth of Massachusetts RECEIVED City/Town of North Andover System Pumping Record NOV 2 4 2008 Form 4 �+ 5 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards ofy be 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 Important: When filling out 1. System Location: forms on the computer,use 625 Boxford Street only the tab key Address to move your North Andover MA 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Chiasson Name Address(if different from location) City/Town State Zip Code 978-691-5498 Telephone Number B. Pumping Record 1. Date of Pumping 10/3/08 2. Quantity Pumped: 1,500 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: Good working condition 6. System Pumped By: Jason Elliott L90-471 Name Vehicle License Number Jason Elliott Septic Pumping Company 7. Location where contents were disposed: GLSD 11110/08 Si �ul Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1