Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 66 VEST WAY 4/30/2018 (2)
Commonwealth of Massachusetts I RECEIVE® City/Town of System Pumping Record JUL 2 20 13 RTH ANDOVER Form 4 PARTMENT DEP has provided this form for usez 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. A. Facility Information 1. System Location: Le i ht iat �fr�ono Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Rilding, Left / Right rear of building, Under deck Address Citylrown State 2. System Owner. Address (if different from location) City/Town F Zip Code State �p _ ` 1 1a. Zia Ctde Telephone Number B. Pumping Record 1. Date of Pumping � � Pumped 2. Quanti . Date p 3. Type of system: ❑ Cesspool(s) Septic Tank Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes D -A -o If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditio 'o stem: pjo\ 6. System Pumped By: Neil Bateson Name Bateson Entemrises Inc Company 7. Loza tio _ere contents were disposed: L S. Lowell Waste Water .. —1 F5821 Vehicle License Number `7-4 _ Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 cf MORIN ,M r o i / � ..•,hoc . f Town of North Andover Animal $ ❑ ,SSACNU`+tt HEALTH DEPARTMENT // f CHECK #:y%'�o� DATE: Body Art Practitioner A<s /eve LOCATION: $ Za H/O NAME: $ CONTRACTOR NAME:,,, 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 $ O Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title -Inspector $ Title 5 Report d� $ 9Q ❑ Other: (Indicate) $ r Health Agent Initials White - Applicant. Yellow - Health Pink - Treasurer =ile;►- Owner information is required for every page. Commonwealth of Massachusetts no- WfflR Title 5 Official Inspection Form Aug 17 2010 Subsurface Sewage Disposal System Form -Not for Voluntary Asses ents 66 Vest Way Property Address Faye Garofano Owner's Name N. Andover CityfTown itv N�STMq � MA 01845 08/04/10 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: key to move your cursor - do not James Wright use the return key. Name of Inspector Aspen Environmental Services LLC Company Name 270 Lawrence St Company Address Methuen City/ Town 978-681-5023 Telephone Number B. Certification MA 01844 State Zip Code 2035 License Number 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 Conditionally Passes ❑ Fails Further Evaluation by the Local Approving Authority Ipspector,s &" ~ ure Date i L", The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owner's Name N. Andover CityT town B. Certification (cont.) MA 01845 State Zip Code 08/04/10 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: Oe"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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <' 66 Vest Way Property Address Faye Garofano Owner Owner's Name information is required for every N. Andover page. Cityfrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 08/04/10 State Zip Code Date of Inspection 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): El-/ 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 B d of Health determines in accordance with 310 CMR 15.303(1)(b) that the syste is not functioning in a manner which will protect public health, safety and the environ nt: ❑ CesspoolXprivy 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owner's Name N. Andover City/Town B. Certification (cont.) MA 01845 08/04/10 State Zip Code Date of Inspection 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ❑/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 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 ❑ EJXor clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ❑� The system is a cesspool serving a facility with a design flow of 2000gpd- 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 sys is within 400 feet of a surface drinking water supply ❑ ❑ e 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 66 Vest Way Property Address Faye Garofano Owner information is Owner's Name required for every N. Andover MA 01845 08/04/10 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 bstructed pipe(s). Number of times pumped: ❑ d Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ D--� Any portion of cesspool or privy is within 100 feet of a surface water supply or to a surface water supply. ❑ �ibutary ny portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [3Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ tom' 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- 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 sys is within 400 feet of a surface drinking water supply ❑ ❑ e 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owrier information is Owner's Name required for every N. Andover MA 01845 08/04/10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No �F] Pumping information was provided by the owner, occupant, or Board of Health ❑ LT 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? ave large volumes of water been introduced to the system recently or as part of ❑ ..this inspection? (� C� Were as built plans of the system obtained and examined? (If they were not available note as N/A) t�j ❑ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? L� IJ Were all system components, excluding the SAS, located on site? ❑ Were L� 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: / Imo' ❑. Existing information. For example, a plan at the Board of Health. l u Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 66 Vest Way Property Address Faye Garofano Owner Owner's Name information is N. Andover MA 01845 required for every page. City/Town State Zip Code D. System Information Description: Number of current residents: 08/04/10 Date of Inspection ' Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15. ): Basis of design flow (seats/p sons/sq.ft., etc.): Grease trap present? Industrial waste h ding tank present? Non -sanitary aste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes No ] ❑ Yes No ❑ Yes �o ❑ Yes No ❑ Yes No A t Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts EMUMM Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owner Owner's Name information is required for every N. Andover MA 01845 08/04/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type, of System: fdd 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owner's Name N. Andover City/Town D. System Information (cont.) MA 01845 08/04/10 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer (locate on site plan): Depth below grade: Ice fee Material of construction: ❑ cast iron 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): i Depth below grade: feet / Material of construction: oncrete ❑ 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: �� L Sludge depth: t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owner's Name N. Andover MA 01845 08/04/10 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? —/j Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum nce 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: feet ❑ polyethylene ❑ other (explain): Date t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 = Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owner Owner's Name information is required for every N. Andover MA 01845 08/04/10 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 ❑ fi ass ❑polyethylene El other (explain).- Dimensions: explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm presenj' ❑ Yes ❑ No Alarm le)�A 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts 11 Me 0 uyuciai inspection Subsurface Sewage Disposal System Form 66 Vest Way Form Not for Voluntary Assessments Property Address Faye Garofano Owner's Name N. Andover MA 01845 08/04/10 State Zip Code Date of Inspection Cityrrown D. System Information (cont.) Distribution Box (if present must be open Depth of liquid level above outlet invert Comments (note if box is level and distribut evidence of leakage into or out of box, etc.) d) (locate on site plan): on to outlets equal, any evidence of solids carryover, any Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: / ❑ Yes ❑ No Comments (note condition of pump glia6ber, condition of pumps and appurtenances, etc.): t Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•'"t 66 Vest Way Property Address Faye Garofano Owner Owner's Name information is required for every N. Andover MA 01845 08/04/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth -top of liquid to i^'-+ —_4 Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins - 09/08 ❑ Yes ❑ No 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 D. System Information (cont.) 01845 08/04/10 Zip Code Date of Inspection 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 etc.): dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 66 Vest Way Property Address Faye Garofano Owner Owner's Name information is required for every N. Andover MA page. Cityfrown State D. System Information (cont.) 01845 08/04/10 Zip Code Date of Inspection 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 etc.): dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way 01845 08/04/10 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: ❑ d -sketch in the area below drawing attached separately Al r4 I I/,4l T /a A/ 7 A/ 1/ r• -* X T r J; o x .-/ / C-3-1 7 17- Iq r ,Zd�/�' b ISA N'.) e_p"Ztt VA, - T / 1z, �� G a L.SonC�>1 <'prl'C rn.,1I C shn t5ins • 09108 1 nin sewage bisposal System - Page 15 of 17 Property Address Faye Garofano Owner Owner's Name information is required for every N. Andover MA page. City/Town State 01845 08/04/10 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: ❑ d -sketch in the area below drawing attached separately Al r4 I I/,4l T /a A/ 7 A/ 1/ r• -* X T r J; o x .-/ / C-3-1 7 17- Iq r ,Zd�/�' b ISA N'.) e_p"Ztt VA, - T / 1z, �� G a L.SonC�>1 <'prl'C rn.,1I C shn t5ins • 09108 1 nin sewage bisposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Vest Way Property Address Faye Garofano Owner's Name N. Andover MA 01845 08/04/10 Cityrrown 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: feet/ Please indicate all methods used to determine the high ground water elevation: Al ■❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �•' 66 Vest Way MA 01845 State Zip Code E. Report Completeness Checklist 08/04/10 Date of Inspection (J-1'rispection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed L=1 System Information — Estimated depth to high groundwater �ketchof Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Property Address Faye Garofano Owner Owner's Name information is required for every N. Andover page. Cityrrown MA 01845 State Zip Code E. Report Completeness Checklist 08/04/10 Date of Inspection (J-1'rispection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed L=1 System Information — Estimated depth to high groundwater �ketchof Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 07/29/2010 15:44 19786889573 PAGE 01101 v Summery Re fd Cdfd a6m,mtcd a 7/29/2010 PM by Lf.. C—a Town of North Andover P� Tax Map # 210-104.E3-0169-0000.0 Parcel Id 16491 &'-7 7770" fib VEST WAY GAROFANO, THaMAS 66 VEST WAY N. ANDOVER, MA 01845 Class 101 Single Family Property Type Size Total 1 Acres 1 Residential FY 2010 UB Malling Index Name/Address Type Loan Number Activeltnact. From Until GAROFANO, THOMAS Payor 66 VEST WAY N, ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17832.0 - 66 VEST WAY Occupant Name Act(v®!Inactive 3170497 03 Cycle 03 Last Billing Date 7/7/2010 Active UB Services Malnt. Account No. 3170497 Service Godo MISCFEE ADMIN FEE Rate Charge Multlpl(arlUsers WTR WATER 0.63518 01 ALL METER St2E 7.82 103.75 1/ /1 UB Meter Maintenance Account No. 3170497 Serial No Status 0028979548 a Active Location Y ENC F.L. Brand METE METE Type Size YTD Cons Date Reading Code Consumption w Water 0.63 0.63 Posted date 229 6/8/2010 5161 m Manual estimate 25 7/15/2010 Variance ° MSG 45/° 3/10/2010 12/11/2009 $1$6 5119 a Actual a Actual 17 4/14/2010 0% 9/8/2009 5101 a Actual 18 58 1/12/2010 10115/2009 70 00 6/9/2009 3/16/2009 5043 6018 a Actual a Actual 25 7/2012009 1 170 ° 3 % 12/8/2008 4990 a Actual 28 25 4/29/2009 1/20/2009 4% 9/8/2008 6/6/2008 4 965 a Actual 17 10/10/2008 52'10 _1% 3/10/2008 4948 4932 a Actual m Manual estimate 16 7/16/2008 6% MSCI 15 4/11/2008 g% 12/12/2007 9/6/2007 4917 4902 a Actual a Actual 15 1/22/2008 .70% 6/20/2007 4862 a Actual 40 34 10/12/2007 7/20/2007 46% 3/15/2007 4828 m Manual estimate 15 4/16/2007 116% 12/1312006 9/13/2006 4813 4798 a Actual a Actual 15 1/19/2007 -10/0 .58% Trouble Code -.03 32 10/20/2006 46% . 8/19/2006 3/9/2006 4766 4740 a Actual aActual 26 7/10/2006 40% Trouble Code:03 14 4/17/2006 6% 12/22/2005 4726 a Actual 16 1117/2006 •74% Trouble Code:03 9/20/2005 4710 a Actual 56 10/14/200$ $6% Trouble Cade:03 X10 R TFC Ott LE° 16 �tiO O ° COCMIL IWKM y^' s PUBLIC HEALTH DEPARTMENT (ommunity Development Division CE1271FTC37E OF C0914PGIANC'E As of: August 17, 2010 This is to cert that the individual subsurface disposal system received a SATIS WTORTIDVSITEMOYof the: W sp&cement of a Component: oistri6ution fox For an On Site Sewage Disposa[System Oy: John Soucy At: 66 fest Wa y Map -104.8; (Parcel'— 0169 9VortkAndover, XX 01845 The Issuance of this certificate shall not de construed as a guarantee that the system will function satisfactorily. 5W,he E. Grant Pu6Cic 5Tealth Inspector 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8416 Web www.townofnorthandaver.com XAORTH LED ,6 O T2 CHCHKy�'` "#4-JACHU'J% PUBLIC HEALTH DEPARTMENT Community Development Division CERTIFIC./`�`� OF'CO�1�1'LIA9VCE As of: August 17, 2010 This is to certih that the individual subsurface disposal system received a SA7IS1FACT0R,`YIYS(EM0Yof the: W sp&cement of a Component: Distri6ution Box Foy an On Site Sewage 1Disposa[System By: John Soucy Tt —.- 66 Vest Way 9Wap-104.B; Parcel— 0169 Forth Andover, 9WA 01845 2%ie Issuance of this certcate shall not 6e construed as a guarantee that the system will function satisfactorily. Michele E. Grant Tu6fcYfealth Inspector 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 2Q. �tl@D /6'6N'\ O 0 `� Oq_ COCMIC Nl wK.t 1' PUBLIC HEALTH DEPARTMENT (ommunity Development Division CE127I1F7CA7E OAF C094pGIA�I�'E As of: August 17, 2010 This is to cert that the individuaf subsurface disposaf system received a SA`IISEWTORTINSPEMOJVof the: ftfitcement of a Component: Tgstri6ution fox Tor an On Site Sewage lisposalSystem By: John Soucy At: 66 Vest % y .flap -104. B; Parcel— 0169 90' rth A. ndover WA 01845 The Issuance of this certificate shaff not be construed as a guarantee that the system wiff function satisfactoriCy. r JKi hefe E. Grant (Public Yfeafth Inspector 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com y ,�.��,sv i6' •YO o `� OHO COCMI(MIWKM _ 7' �t PUBLIC HEALTH DEPARTMENT Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: MAP: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: LOT: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 V No PUBLIC HEALTH DEPARTMENT Community Development Division testing 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection form June 2008 ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection form June 2008 O2 PUBLIC HEALTH DEPARTMENT /� Community Development Division (Z/ - ISTRIBUTION-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: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as PUBLIC HEALTH DEPARTMENT /� Community Development Division (Z/ - ISTRIBUTION-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: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 PUBLIC HEALTH DEPARTMENT Community Development Division SYSTEM ELEVATIONS BM = HR= HI = ROD ELEVATION AS -BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT . Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 SKETCH PLAN 16 O lL A y `� OAC COCNIC MI WKM _ 7' #/ PUBLIC HEALTH DEPARTMENT (ommunity Development Division 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 K PUBLIC HEALTH DEPARTMENT (ommunity Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: Q � � (-Address of septic system) Relative to the application of (Installer's name) Dated )n o ay ate For plans by (E gineer) And dated With revisions dated I understand the following obligations for management of this project: xigina ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection without completion of the items in accordance with Title 5 and the Board of Health Regulations may,result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (VS inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept&townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as tier the approved plans No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. /1 Undersigned Licensed Septic Installer: (T day's Date) aG� CLIl Name —Print) (Name i ft L o f; A l.;bo(:-/)! SS TJC Tnn; V!7.4 fl.rVIIT/nni 7;A/►/[ -'TS -t- n M K /,A/ An/A' 0 1T Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key "U Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED SEP 2 2 2008 DEP has provided this form for use by local Boards of Health. Other fofmsYi a�-bil5sed; buftF e J information must be substantially the same as that provided here. Bef"—us ng ithis=fo�rn; cheGc-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. A. Facility Information 1 System mLLocation \ � Address Cityrrown (K�J• v 2. System Owner: Name Address (if different from location) Cityrrowm B. Pumping Record 1. Date of Pumping Zip Code State Zip Code Telephone Number Date Quantity Pumped: (-S—Clfl-- Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [rNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condiittiioon of System: \ D �A'aj W—� � 1-k s. syster>It Pgmped By: ,, a Name Vehicle License Number Company 7. Location whe contentre -1 -7 --��- Date t5form4.doc- 06/03 System Pumping Record - Page 1 of 1 w�= Co'm'monwealth of Massachusetts Map -Block -Lot 104.60169 ----------------------- Board of Health Permit No • North Andover BHP -2010-0705 -------------------- P.I. FEE ,.a r'gfi^ $125.00 Ss�ca F.I. -- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John_ Soucy to (Repair -D -BOX ONLY) an Individual Sewage Disposal System. at No -66-VEST-WAY as shown on the application for Disposal Works Construction Permit No. BHP -2010-0_____ Dated August _16, 2010--___ --------------------- -------- --------- FILE COPY Issued On: Aug -16-2010 Board of Health Commonwealth of Massachusetts Map -Block -Lot 104.60169 a Board of Health ----------------------- North -- ------------------North Andover . 4 CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -D -BOX ONLY) by ___John Somy-_ - Installer at No -66-VEST-WAY has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. 13HP-2010-070 _ Dated ---August 16, 2010 ----- Printed On: Aug -16-2010 Board of Health A 4O RTN v . �"I A l j , Town of North Andover HEALTH DEPARTMENT S�cNust CHECK #:Q/ D TE: /Q. LOCATION: H/O NAME: CONTRACTOR NAME: 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 $ eptic Disposal Works Construction (DWC) $119 ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q renrn Application for Septic Disposal System i6i© Construction Permit 'TOWN OF TOY'S DATE $ 250.00 - Full Repair $125.00 - Components% Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑pair or replace an existing on-site sewage disposal system* (0 ( Repair or replace an existing system component - What? 10 hoe A. Facility I Address or Lot # City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information f 64At� 3. Name Address (if different fromab ve) City/Town Name Addres` J r City/Town �i� W f of Ott/ State Zip Code C-i?5C Gv t3=S-707 Telephone Number Name of Comp ./Vff State c� 3.�?'1 Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Information '411.4 - Name V I r I Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 i Application for septic Disposal System (Construction Permit -TOWN OF PAGE 2®F2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or ❑Commercial B. Agreement 1 la 10 TODAY'S ATE $ 250.00 - Full Repair $125.00 - Component tZ The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewaspoffsal system in accordance with the provisions of Title 5 of the Environm ta/ ode, as well as the Local Subsurface Disposal Regulations for the Town of North 44dove , and not to place the system in operation until Certi 'cate of Compliance has b;7'rss=ard of ealth. l tv t e Date Applic on Approved By: oard of Health Representative) a Date Application Dis proved or the following reasons: For Office Use Only: / 1. Fee Attached. Yes Ll No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Ssy tem? If so, Attach copes of Electrical Permit Yes No 4. Foundation As -Built? (new construction ronly): Yes No (same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 -C\- Commonwealth of Massachusetts AMR City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. be submitted to the local Board of Health or other approving a A. Facility Information RECEIVED APR -- g 2007 System Pumping Rec it!l.' OF NORTH ANDOVER HEALTH DEPARTMENT must Important: When filling out forms the 1. System Location: L% a� computer, use only the tab key to move your Addres cursor - do not use the return . QityfTown State Zip Code key. 2. System Owner: Name Address (if different from,location) CityfTown State f --Zip odea Telephone Number TOWN OF N -"L/ -C,-/ SYSTEM PUMPING RECORD OF NOF, :��61�JyC OGH:E D OF i'�Lf�+Li f7 DATE:`" .�., . JAN - 8 2004 ............ SYSTEM OWNER & ADDRESS 6 6 Uas-,� DATE OF PUMPING: SYSTEM LOCATION- (example: OCATION(example: left front of house) euz QUANTITY PUMPED: /(:S)0z-, GALLONS CESSPOOL: NO SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE `' EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACETULD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D �—'� Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: .'STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: — QUANTITY PUMPED 1 SOD GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) co CONTENTS TRANSFERRED TO: Com onwealth of Massachusetts j��aw �,4j , Massachusetts System Pumping Record System Owner CAX0 -(;L� Date of Pumping: 6 ( i Cesspool: No H---, Yes [] System Pumped by: &&"W System Location 6r. (- U)QA) Quantity Pumped: 1(5�gallons Septic Tank: No [ ] License # Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: Yes F} V Yc X ¢ dn '- r Xa'�iW; i ' ass tVlttlsert( t A - rr .,., !k a,•6ytz er � �:� ak t�.§ rlx 'S rc z v � � q �dt �r FR 'urnr��n Sygtelll V .0 /��Vilet Systetrt LuctitidH 5 1 r< x Am�a+10c (/���J.�� , 1 n i n %� � 9 .ki ri'@ '" �f 1i'•+• �,S M � �'.�r,,fi owl MAN sv iiY""'' _ - . � w tw .� $���L 'r�?;�� +'H' �S'F�• k�"i >ri'"r �, Dale of I'uuqpng: �uahtit Pumped jr /y, - r , r s "'.^441 't'� .,a'a'�aAT`-'¢r� .�•,. / r. �r J y y� „fir;��FE raj Mt a Gess x)cil: No ties USeMitic 7 t�tik' ftf'k r r l eg } 'N System !lumped by: 0....4.4 Ci!'ee"MF.�! Toss"", :. s .r Z z yf,z � 1"k ti "* .�a. �d�• i� INAF P 4�5 yza$.�s {l+y��. i'T7tv''y�r Cotrlet�ts twisrettteq of Oreut ti 4 K'4 Y. e � a Ad �F� ..� t�r�' � { �' tx+y�:�°�fS n< §a'tNt �F y�sr � �•t����yb. �R� / t� �'� di ✓ YJ +�''•�6[ 3N ¢"t 4iL1C �.1y�, - -' 8 r Y 1°,y �+t• � to Lf i'r �5 'tT' S N �nA�" � �`� rR Fla- }�.�r ' fr lg .4 "+•F'4Y 4 '4° Y5y1< Jq fhj W+�1��"�fk l Date: "tIv, ri # } + � S a- . � 7 "v ,l� °fit � Y X4 �� Y ,ik 1 ;` ���a f !✓ a �{ � g NNE �a 8 y d"l ae a i��g rPi; h a`rvA" r r�rr i`t yx i pt�µ t i5rutw. r "i'*�v^r' � t•, �! � turd k �`� b'�t� "'i 6 �z . Syn A rla`�'kusa,e.+b�• s4 . F, 'k Y:'rf f�i ::��'� � �t NOR tr "�3 1� �r3t .��6t a,+$a J.•� ���"�' �.4 .iz.,yys , . �:: N r4�' � ,r b'' k sbid''>�pt�i'�.:a .j„ ° C V� ""�`"t #� a�� i��`" 3`' 4.����Y�✓�'a�'4 .- a t N v er,� a* >n� sY.N;. A[kaF ; �" :, �'y t�tll }v� •�v � „�y��r4 �l*N i , 1r -0. ' ti� a° � 'r .'�s � .� �..'�td:l ,r't3��t�'•'�r`�crs tr ':'3� Y�,rb�,�,�`'s"tr �yk �S ..��`���x �.�'> "`£ s, • - i { ° ( '' w7u 3s''i k" v i b r Fir Ek e-r'a' 'F �"u ` y r�v'Jr Da. x eek * s ck r'S MM w W t, . lots ` -. ``e u ::,, r...0 1�� 4�3t i , 4K,a>Fr:.a"S,';�,; r . FORM A - SYSTEM Ph[PL\G RECORD Comtnonwealth of Massachusetts , Massachusetts system Pumping Record ystem Owner System Location Date of Pumping Quantity Pumped: Cesspool: No Yes ❑ Srntir TnnL,- NIS �] Yes D System Pumped b\ License #: Contents transferred to: Date Inspector ;ORTFi PUBLIC HEALTH DEPARTMENT Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: MAP: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: LOT: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cieanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 V NORT11 O��t�ec �6q�0 O c� I `� Oq_ COCMI<KtWKK _ 1' PUBLIC HEALTH DEPARTMENT Community Development Division testing 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 V NORTf{ o�,stLeo ,6q�0 ♦< � T '�'J1` � TAA�O COCMiC N�wKM y7' PUBLIC HEALTH DEPARTMENT Community Development Division 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: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 NORTH Q��t VEO �6 qN vy � coca 2.w�� . + # PUBLIC HEALTH DEPARTMENT Community Development Division SYSTEM ELEVATIONS BM = HR= HI = ROD ELEVATION AS -BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 SKETCH PLAN pORTH O�4t►.eo 06,q�U O to � L � PUBLIC HEALTH DEPARTMENT (ommunity Development Division 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 pORTII OF�t�aD 16�'EO O t6 4 T `� DSO cocnii�iwicw . 1' */ PUBLIC HEALTH DEPARTMENT (ommunity Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well ' 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 FORK U - LOT. RELEASE FORK 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT Phone 1,140,- S 3 S4 LOCATION: Assessor's Map Number Parcel Subdivision Lots) 5 Street St. Number l�(� ************************Official Use Only************************ RE DATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments :, Town Planner Comments Food Inspecto -Health --Se is nspector-Health Comments i Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected 'Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date