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Miscellaneous - 67 RALEIGH TAVERN LANE 4/30/2018 (2)
C I ■ SPCCiA6 vcSTE opgoAto /%yl4y Td 1gLtoCJ Tfr:iS f SUS*I�[.L A ria/J SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT PAID? YES NO DWC PERMIT NO. 9w [1 INSTALLER:lA o Cu,e2iE� BEGIN INSPECTION YES N0: EXCAVATION INSPECTION: NEEDED: PASSED BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YE -IAA APPROVAL TO BACKFILL: DATE: I �� BY IJA FINAL GRADING APPROVAL: DATE BY ,,,i�o FINAL CONSTRUCTION APPROVAL: DATE: Z / BY /� � I ov Scan November 17, 2015 REC DEC 14 2015 Mr. Darrell Hamann TOWN OF NORTH ANDOVER 67 Raleigh Tavern Lane HEALTH DEPARTMENT North Andover, MA 01845 RE: Maintenance and Service Contract for the Recirculating Sand Filter System located at 67 Raleigh Tavern Lane, North Andover Dear Darrell: Clear Water Industries (CWI) proposes to provide service and maintenance for the Recirculating Sand Filter(RSF) System at the above referenced address. The following maintenance and service schedule is for the next two (2) years of operation commencing upon receipt of signed contract and Annual Cost received in full. Scheduled Annual Service: Annual Cost: 1 inspection and I field effluent testing = $305.00 (Note: Access cover for all components must be at the ground surface.) 1. Check scum and sludge depths in both compartments of the septic tank. 2. Clean the effluent filter in the septic tank. 3. Check panel and alarm system. 4. Check ejector pump and float switches in Recirculating Pump Chamber and the Dosing Tark. 5. Take effluent sample as required by Massachusetts D.E.P. Sample will be analyzed for the following: *Dissolved Oxygen, *Turbidity, and W. 6. Notify Client verbally of any problems encountered. (Note: There may be instances when the high water alarm will sound. In the event of an alarm condition, you are requested to silence the audible alarm and contact (978) 356-0779 for instructions and/or a follow-up field visit by a CWI representative. See unscheduled service costs.) I have read and agree with the above Scope of Work: CWI's initials-2 _ol Owner's initials �� PO Box 825, Ipswich, MA 01938 . 978-356-0779• Fax 978-356-5500 •www.clearwaterindustries.com Page 2 Mr. Darrell Hamann November 17, 2015 Unscheduled service: 1. Unscheduled emergency service calls will.be billed at the following hourly rates: *Monday through Friday lam—5pm: $95 *Monday through Friday 5pm— 7am: $150 *Saturday and Sunday: $150 with a minimum of a 2 hour charge. 2. If results of field effluent testing for pH, Dissolved Oxygen or Turbidity do not comply with Massachusetts Department of Environmental Protection limits, additional testing for Total Suspended Solids and Biochemical Oxygen Demand would need to be done at a certified laboratory. Owner would be contacted prior to additional testing. Additional testing of effluent would be $95.00 per sample. Certified technician: The service technician shall be a Massachusetts Certified Operator. The certified operator will be David F. Clark, George F. Norris, Mark Cottrell, Mario Rosa or James Griffin. Reporting requirements: In accordance with DEP's Title V Regulations, CWI will file annual report with the property owner and the local Board of Health. Annual report will be forwarded to the DEP transmitting the data from the sampling of the effluent, as well as a review of any unscheduled service. Sincerely, Clear Water Industries David F. Clark Manager Acceptance by Owner: Darrell Hamann Date PO Box 825, Ipswich, MA 01938 .978-356-0779 • Fax 978-356-5500•www.clearwaterindustries.com Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH Q "� ~6f Vn nD 2 .`mb APPLICATION FOR SITE TESTING/INSPECTION �1 AD RATED 0 �SSACHUS�� Applicant 1 Glnt� — Pft±A t ,C—LQ- � PSL. NAME ADDRESS TEJ.EPHONE Site Location �C ��� Engineer NAME ADDRESS TELEPHONE Test/I nspection Date and Time A�'OU �; � �� �o'4C P" CHAIRMAN,BOARD OF HEALT � Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. FORM 11 SOIL EVALUATOR FOR1%1 C, Page 1 'j. Date...P.".7 F1...... No. .................................... �- :,�.Com-mblnwealth of Massachusetts Massachusetts Soil Suitability Assessment for On-site Sey_aee Usposal Performed By: .......... ............../ ......................................... ............................ Witnessed By: ....... .......... ............ ................................................................................................................................................................................................................................................................... Lmdon Address or -2 a/," Oww's Nm, r2l,Ck Ad&as,wW Telephone# 4�1 30 New construction El Repair EB./ Office Review Published Soil Survey Available: No 0 Yes Year Published Publication Scaile Soil Map Unit Drainage Class .........t Soil Limitations .......................................................................................6�.A Surficial Geologic Report Available: No Yes El. Year Published ................... Publication Scale .................. GeologicMaterial (Map Unit) ........................................................................................................................................................... Landform .............................................................................................................................................................................................................. Flood Insurance Rate Map: Above 500 year flood boundary No El Y e s Within 500 year flood boundary No LAY Yes ❑ Within 100 year flood boundary No Yes El Wetland Area: National Wetland Inventory Map (map unit) ................................................................................................................. Wetlands Conservancy Program Map (map unit)................................................................................................... Current Water Resource Conditions (USGS): Month .................. Range : Above Normal El Normal ❑ Below Normal El Other References Reviewed: 1,(5eo"-T j04 ITQ FORM 11 - SOIL EVALUATOR FORM Page 2 On-site Review Deep Hole Number Apn.:T Date:-67.- 5 f� Time:.....<.. Weather .. ................ Location (identify on site plan) .......�4.x.'PkU41.......................................................................................................................................... LandUse .......X-C................................... Slope M Surface Stones ......P7,07.'.-o.......................................................... VegetationL4k&v............................................................................................................................................................................................................... Landform ......... .. .............. ....................................................................................................................................................................................................... Position on landscape (sketch on the back) ....................................................................................................................................................... Distances from: Open Water Body feet Drainage way lav'.t feet Possible Wet Area A&,..t4.- feet Property Line ....;?V.!t.. feet Drinking Water Well feet Other ......................................... DEEP OBSERVATION HOLE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (Inches) (USDA) (Munsell) (Structure,Stones,Boulders, Consistency, %Gravel) tq for /0 lk3 WA Y V, ...................................................................... Depth to Bedrock: .... Parent Material (geologic) ............... .. ..... ....................... Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: ..........-... FORM 11 - SOIL EVALUATOR FORM Page 2 On-site Review Deep Hole Number Date: 4.7�Z �9- Time:..... Weather ......7...F Location (identify on site plan) ............. .1............................................................................I........................................................ LandUse ......40..................................... Slope M Surface Stones. ................................................................................ Vegetation ............. ................................................................................................................................................................................................... Landform .............. 0r..... ......................................................................................................................................................................................... Position on landscape (sketch on the back) ......................................................................................................................................................... Distances from: Open Water Body feet Drainage way... feet Possible Wet Area 1P.3f feet Property Line feet Drinking Water Well feet Other ......................................... EP OBSERVATION HOLE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (inches) (USDA) (Munsell) (Structure,Stones,Boulders, Consistency, %Gravel) (-7 IV C- 9/6 Parent Material (geologic) .................. .............................................................................. Depth to Bedrock: ... Depth to Groundwater: Standing Water in the Hole: ..PJAU— Weeping from Pit Face: 0011-1-�- Estimated Seasonal High Ground Water: ............. FORM 11 - SOIL EVALUATOR FORM Page 3 Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side of observation hole................... inches Depth to soil mottles . .... inches �v ❑ Ground water adjustment feet Index Well Number ................... Reading Date ................... Index well level ................... Adjustment factor .................. Adjusted ground water level ........................................................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? df' If not, what is the depth of naturally occurring pervious material. Certification I certify that on (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature14 _ Date 0' D.F. CLARKz�C� TITLE D.F. CLARK, INC. off' SEPTIC SYSTEM PROFESSIONALS INC. June 15, 2011 FtoHWUMALTH OF NORTH A DOVOR ORPARYM MP Mr. Darrell Hamann 67 Raleigh Tavern Lane North Andover, MA 01845 RE: Title 5 Inspection 67 Raleigh Tavern Lane,North Andover Dear Darrell: Please find enclosed the Subsurface Sewage Disposal System Inspection Report for the above referenced property. As noted on Part B (Certification) of the report, the system Passes the inspection criteria. This inspection is good for the next two (2) years; you may extend the life of the inspection to three (3) years by having the septic tank pumped annually (before anniversary date of inspection). Thank you for allowing us to be of service to you on this project. Please contact us if you have any questions regarding this matter. Sincerely, D.F. Clark, Inc. George F. Norris Title 5 Inspector J Enclosure cc: VNorth Andover Board D.F. Clark, Inc. file PO Box 265 24A Mitchell Road Ipswich, MA 01938 978-356.5638 Fax 978-356-5500 Toll Free 888-DF-CLARK D.F. CLARKZ TITLE D.F. CLARK, .INC, off' SEPTIC SYSTEM PROFESSIONALS INC. --,71 June 15, 2011 TOWN OF NORTH MOOVOp HGALTW 0GPAATMLNYJ Mr. Darrell Hamann 67 Raleigh Tavern Lane North Andover, MA 01845 RE: Title 5 Inspection 67 Raleigh Tavern Lane,North Andover Dear Darrell: Please find enclosed the Subsurface Sewage Disposal System Inspection Report for the above referenced property. As noted on Part B (Certification) of the report, the system Passes the inspection criteria. This inspection is good for the next two (2) years; you may extend the life of the inspection to three (3) years by having the septic tank pumped annually (before anniversary date of inspection). Thank you for allowing us to be of service to you on this project. Please contact us if you have any questions regarding this matter. Sincerely, D.F. Clark, Inc. F F N : George F.Norris Title 5 Inspector Enclosure cc: VNorth Andover Board of Health D.F. Clark, Inc. file Oil PO Box 265 24A Mitchell Road Ipswich, MA 01938 978-356-5638 Fax 978-356-5500 Toll Free 888-DF-CLARK i� Commonwealth of Massachusetts .ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your George F. Norris cursor-do not Name of Inspector use the return key. D.F. Clark, Inc. Company Name r� 22 Mitchell Road, P.O. Box 265 Company Address Ipswich MA 01938 renon Cityrrown State Zip Code (978) 356-5638 S14051 Telephone Number License Number B. Certification 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 ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M •'" 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every page. Cityrrown 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: ® 1 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: System is maintained twice a year by Clear Water Industries, last maintenance report and copy of current contract attached. Ratio box is in good condition. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every 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 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 or 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 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every page. City/Town 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 11 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 u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been.introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,•''r 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every page. City[Town State Zip Code Date of Inspection D. System Information Description: As per design plan Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Currently Occupied 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts u u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: System was last pumped one(1) year ago according to the owner. 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: ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every 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: System was installed in the 1997 according to the owner. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below 9 feet rade: feet (37") Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe is in good condition no signs of leakage. Septic Tank (locate on site plan): Depth below rade: feet (29") P 9 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 5'Wx10' Lx4' D Dimensions: 5" Sludge depth: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every page. CitylTown 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape measure and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees are in place, liquid level is normal, septic tank is in good condition and pumping is not required at this time. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts IMPW Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every page. Cityrrown 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): i 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.): i, *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts M w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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.): The pumps and floats in both the Recirculating and Dosing chambers are working properly. All floats were cleaned during the inspection. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every 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: fild - 30'W x e ® leaching fields number, dimensions: 1 1 field l ❑ 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.): SAS is Pressure Distribution, SAS is under lawn area in the front yard, flushed all five (5) laterals, there are no signs of ponding or hydraulic failure 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every page. Cityfrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M W' 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is required for North Andover MA 01845 June 8, 2011 every 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: ® hand-sketch in the area below ❑ drawing attached separately Deck Sunroom A Sand ilter Porch 3 42— Septid Tank (Out] t w/filter) water ° B p sewer p #1 —Septic Ta • (Inlet cover) Paved Driveway Rati O 44—Dosing Pump Chamber #3 —Recirculating amber A- 1 = 13'8" B- 1 = 12'6" A-2 =20' B-2 = 18'6" A-3 =25' 14Swich, , B— 3 = 16'8" A-4 = 33'10" D.F. �, B—4 = 30'8" CLARK INC. t5ins•09/08 �—/8)356-c6�� Title 5 Official Inspection Form:Subsurface 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 M 67 Raleigh Tavern Lane Property Address Darrell Hamann _ Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every page. 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: 3 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: August 27, 1997 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: Soil testing was performed on June 25, 1997 by B. Dufresne, ESHGW was determined in both test holes- OP3 @ 38" and OP-4 @ 36", according to design plan bottom of SAS is 4' above ESHGW in hole OP-4. At time of inspection a site exam was made, slope was level, no surface water was observed, cellar was dry with a sump pump and no shallow wells were located. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Raleigh Tavern Lane Property Address Darrell Hamann Owner Owner's Name information is North Andover MA 01845 June 8, 2011 required for every page. Cityrrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Vh July 10, 2009 Mr. Darrell Hammann 67 Raleigh Tavern Lane North Andover, MA 01845 RE: Maintenance and Service Contract for the Recirculating Sand Filter System located at 67 Raleigh Tavern Lane,North Andover i Dear Darrell: Clear Water Industries proposes to provide service and maintenance for the Recirculating Sand Filter(RSF) System at the above referenced address. The following maintenance and service schedule is for the next two (2) years of operation commencing upon receipt of signed contract and Annual Cost received in full. Scheduled Annual Service: Cost: 2 inspections and 2 field effluent testing @ $205 = $410 (Note: Access cover for all components must be at the ground surface.) 1. Check sludge, scum depth and clean the effluent filter in the septic tank annually. 2. Check panel and alarm system. 3. Check ejector pump and float switches in Recirculating Pump Chamber and the Dosing Tank. 4. Take effluent sample as required by Massachusetts D.E.P. Sample will be analyzed for the following: *Dissolved Oxygen, *Turbidity, and *pH. 5. Check function of Recirculating Sand Filter. 6. Flush out Pressure Distribution field as needed. 7. Notify Client verbally of any problems encountered. (Note: There may be instances when the high water alarm will sound. In the event of an alarm condition, you are requested to silence the audible alarm and contact (978) 356-0779 for instructions and/or a follow-up field visit by an CWI representative. See unscheduled service costs.) I have read and agree with the above Scope of Work: lL CWI's initials`L Owner's initials PO Box 825, Ipswich, MA 01938 . 978-356-0779 - Fax 978-356-5500 -www.clearwaterindustries.com Page 2 Mr. Darrell Hammann July 10, 2009 Unscheduled service: 1. Unscheduled emergency service calls will be billed at the following hourly rates: *Monday through Friday lam—5pm: $85 *Monday through Friday 12am—7 am, 5 pm— 12pm: $100 *Saturday and Sunday: $100 with a minimum of a 2 hour charge. 2. If results of field effluent testing for pH, Dissolved Oxygen or Turbidity do not comply with Massachusetts Department of Environmental Protection limits, additional testing for Total Suspended Solids and Biochemical Oxygen Demand would need to be done at a certified laboratory. Owner would be contact prior to additional testing. Additional testing of effluent would be $95.00 per sample. Certified technician: The service technician shall be a Massachusetts Certified Operator. The certified operator will be David F. Clark, Steven S. Cottrell, George F. Norris or Mark Cottrell. Reporting requirements: In accordance with DEP's Title V Regulations, CWI will file semi-annual reports with theproperty owner and the local Board of Health. Annual reports will be forwarded to the DEP transmitting the data from the sampling of the effluent, as well as a review of any unscheduled service. Sincerely, Clear Water Industries David F. Clark Owner Acceptance by Owner: Darrell Hammann Date PO Box 825, Ipswich, MA 01938 .978-356-0779 • Fax 978-356-5500 •www.clearwaterindustries.com c j 'rlOw— 4Y :r?�61, RECIRCULATING SAND FILTER SYSTEM ROUTINE INSPECTION ADDRESS: 67 Raleigh Tavern Lane, North Andover OWNER: Hamann DATE: December 16, 2010 OPERATOR: Mark Cottrell SYSTEM STATUS Septic Tank Effluent Filter: Cleaned, rinsed out Scum Depth: 051/48" Sludge Depth 453/48" (Measured on December 3, 2009) Recirculating Pump Chamber Pump H-O-A Setting: Auto Pump Cycle Timer: N/A Alarm Selector: On Level Alarm: Normal Exercise Pump: Yes Test& Clean Floats: O.k., cleaned Tank Condition: Good Dosing Pump Chamber Pump H-O-A Setting: Auto Pump Cycle Timer: On Demand Alarm Selector: On Level Alarm: Normal Exercise Pump: Yes Test& Clean Floats: O.k., cleaned Tank Condition: Good Sand Filter Sand Condition: Clean Diffusers Condition: Clear, flushed and brushed all (3) laterals on 12/16/10 Effluent Quality Visual Inspection: Clear, no odor Sample: pH= 6.5, Dissolved Oxygen= 8.75 mg/L, Turbidity=2.85 NTU Comments: Signature: Certificate # 11739 PO Box 825, Ipswich, MA 01938 . 978-356-0779 • Fax 978-356-5500 • www.clearwaterindustries.com Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 RSF System Operation and Maintenance Inspection Checklist A. Installation & Service Information 67 Raleigh Tavern Lane December 16, 2010 Facility Street Address Date of Service North Andover Mark Cottrell/Clear Water Industries City Operator/O&M Firm Inspect& note B. Septic tank(s) if pumping is required. Sludge Pumping Required: Yes ❑ No X X Sludge Depth: 4" Inspect& clean effluent tee Effluent tee filter: Yes X No ❑ If yes, inspect X&clean at least yearly X filter. Clean as C. Recirculation tank necessary. Inspect for ❑ Check if sludge accumulating Pumping required: Yes ❑ No X sludge. Odor problems: Yes ❑ No X If yes,description Inspect for D. Equalization tank (if installed) sludge. ❑ Check if sludge accumulating Pumping required: Yes ❑ No ❑ Inspect pumps E. Pumps, switches, floats, alarm system & electrical switches, test' X Pump Inspections (all units) as necessary. If problems,describe Run pumps in X Test pump alternator, or record hours Not applicable for this system manual mode. Hours of operation Record X Float switches O.k. readings from Check all switches for operation meters & X Test alarm counters. If non-functioning,corrective action(s) Note if weeds &F. Recirculation Sand Filter debris are present on bed. X Inspect for ponding Ponding Present: Yes ❑ No X Clean/maintain bed surface to X Clean bed: Yes X No allow proper operation of the X Distribution pipes Flush: Yes X No Brush: Yes X No system. X Check head loss in pipes O.k. Headloss and comments G. Sample Collection (Field Sample) Yes X No If yes: BOD TSS X pH ❑TN X Other- Dissolved Oxygen and Turbidity rsfcheck- 1/11/11 Page 1 of 1 Ll5Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and 0&M Form for Title 5 I/A Treatment and Disposal Systems A. Installation Important: Darrell Hamann When filling out Owner forms on the computer,use 67 Raleigh Tavern Lane only the tab key Facility Street Address to move your North Andover 01845 cursor-do not City Zip use the return key' Mailing address of owner, if different: Street Address/PO Box: City State Zip ( ) - ext. Telephone Number B. Authorized Service Provider Clear Water Industries O&M Firm P.O. Box 825 Street Address Ipswich MA 01938 City State Zip (978) 356 -0779 ext. Telephone Number Mark Cottrell 11739 Certified Operator Name Certification Number C. Facility/System Information DEP ID Manufacturer ID Model Number Installation Date Start of Operation Approval Type: ❑ General ❑ Provisional ❑ Piloting ® Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information December 16, 2010 June 1, 2010 Inspection Date Previous Inspection Date Sludge Depth(to be checked yearly) Pumping Recommended El Yes ® No t5aiom.doc•rev. 11-07-05 Page 1 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and 0&M Form for Title 5 IIA Treatment and Disposal Systems E. Field Testing Field Inspection: Color: ❑ gray ❑ brown ® clear ❑ turbid ❑ Other(specify): Odor: ❑ musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ❑ no ❑ some pH 6.5 SU DO 8.72 mg/t- Turbidity 2.85 NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: Notes and Comments: Field sample was clear with no odor. t5aiom.doc•rev. 11-07-05 Page 2 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and 0&M Form for Title 5 I/A Treatment and Disposal Systems H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massachusetts certified operator in accordance with 257 CMR 2.00. 41 December 16, 2010 Operator Signature Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use—by January 31St of each year for the previous calendar year Piloting Use -within 45 days of inspection date Provisional Use—by March 311h of each year for the previous 12 months General Use—by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 t5aiom.doc•rev. 11-07-05 Page 3 of 3 Form No.4- Town Town of North Andover, Massachusetts BOARD OF HEALTH December 11 , 1997 CERTIFICATE OF COMPLIANCE _ This is to certify that - the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ) -- - --= by David Currier _ INSTALLER at —67 Raleigh Tavern Lane-_. -SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. dated 19 The issuance of this certificate shall not be construed as a guarantee that the system will.— function satisfactorily. 4T _ BOARD OF HEA Ft _ - - v-i-- -.... .. - A:. a c c ire c»• l rvi i ULUUl.t51 tK HtHL I H (/th'I . 1 508 281 97213 P.02 ' )FORM 3A• CERTIFICATE OF COMPI.L Na COMMONWEALTH OF MASSACHUSETTS - Board of Health, No&LtI AVDo11j5 , MA. CERTIFICATE OF COMPLIANCE T � De wdption of Work: ❑ Individual Component(s) 19 Complete System ---The.undersigned .hereby certify that the Sewage Disposal System; Constructed X Repaired.( ), upgraded { ), Abandoned t ) at. a '1 has been installed in accordance with the provisions of 310 CMR 15.00 (Title 51 and-the approved design plans/akuilt plans relating to application No. dated Approved Design Flow(gpd) Installer e__ / uesigner. inspeCtor tate - The issmance of this permit shall not be construed as-a guarantee that the system will ' function as designed. r - OE?APMtOVW FORM V% TOTAL P.02 PLAN REVIEW CHECKLIST ADDRESS_ �i9�, /�'/� T�y ENGINEER GENERAL / 3 COPIESy STAMP LOCUS C-� NORTH ARROW SCALE CONTOURS PROFILE V-"(Sc) SECTION ✓ BENCHMARK -- SOIL & PERCS ELEVATIONS WETS . DISCLAIMER X'`' WELLS & WETS WATERSHED? N© DRIVEWAY WATER LINE FDN DRAIN M&P SCH40 A-- TESTS CURRENT? ✓ SOIL EVAL b SEPTIC TANK �'G 5 MIN 150OGy . 17 INVERT DROP Z--" GARB. GRINDER A �(2 comps +200) 10 ' TO FDNJ)� MANHOLE `/ ELEV GW # COMPS . GB D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET - OUTLET = (2" OR . 17 FT) TEE REQ'D? LEACHING MIN 440 GPD? RESERVE AREA' 4 ' FROM PRIMARY? — 20 SLOPE 100 ' TO WETLAN15S 100 ' TO WELLS 4 ' TO S .H.GW f(5 ' >2M/IN) 20 ' TO FND & INTRCPTR DRAINS lC 400 ' TO SURFACE H2O SUPP i 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? x/ ( 15 ' ) BREAKOUT MET? ,\<' TRENCHES MIN 440 gpd SLOPE (min . 005 or 6"/100 ' ) SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MIN. 4" PEA STONE? VENT? ( >3 ' COVER; LINES >50 ' ) BOT + SIDE = X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright © 1996 by S.L. Starr IV ell, � (��� Viol 5 J�V��) fo PITS MIN 440 LEACHING MIN 1 (13 'x16 ' ) PIT MANHOLE PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x ##) (G/ft2 ) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE . 005 BED/TRENCH (Bed max. 60 ' X 60 ' ) MIN 13 ' X 16 ' PIT BOT + SIDE X LOAD = TOTAL ( L x W x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS MIN 440 GPD 900 ft2 BED !/ GW MIN 4 ' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? +" PEA STONE? — DIST LINE SLOPE . 005? >31COVER-VENT '� SCH 40 MIN 12" COVER L� RATE ( X ) X = TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol . DISCHARGE SIZE 4C G 36DISCHARGE RATE DISCHARGE TIME �J- 'y/ gpm MANHOLES TO GRADE ALARM SEP. CIRC. y GW (Min. l ' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? TDH ' WEIGHTED? Copyright © 1996 by S.L. Starr Town of North Andover, Massachusetts Form No.3 t koRT#l, BOARD OF HEALTH ` O ti[eo yet 1.0 /J _ /.. -xf 31 19 • O � DISPOSAL WORKS CONSTRUCTION PERMIT SACHUSE Applicant �V�t1l� �L>/Z2IE2. Y NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair 1nindividual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 410"e 'f CHAIRMAN,BOARD OF HEALTH ,- 966 Fee D.W.C. No. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:- 0� -.3O.-1?7 CURRENT INSTALLER'S LICENSE# LOCATION: 7 IZe z( i9� LICENSED INSTALLER: i�,�,'� SIGNATUR . � ! TELEPHONE# CHECK ONE: REPAIR: X NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes �� No Foundation As-built? Yes No Floor plans on file? Yes No Approval , ____-- Date: Pdrtnit 116 Lot 30 Raleigh Tavern Rd. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION Curtis Dev Co . HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereb� make application for a permit for a sewage disposal installation at Lo 30 Raleigh Tavern Rd. 0 I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 1000 in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 200 lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia. ) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed, A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements That may be attached to the permit. Plot Plans must be submitted with application. DATE 510169 Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE 518169 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as describe . DATE 1® G r- Signature of Unspecting Officer Percolation Test 6 NUmtes Soil: Clay Garbage Grinder BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. i Y 1. NAME 60 DATE �/� / &y T f 0 2. ADDRESSLOT NO. &O- TEL. 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS SEWAGE DISPOSAL DATE r NAME OF APPLICANT LOCATION _c � 0 Address I f-lot no, BUILDING: Dwelling Other SYSTEM: New D( Repair GENERAL DESCRIPTION OF LAND SUBSOIL: Clay D� Uavel Sand PERCOLATION TEST 6 minutes per inch, MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK gallon capacity. LEACH FIELD 2_t�-e lineal feet of drain pipe, 4.illiam J. r' scoll , Engine. Board of Hea h Town of North Andover NORTI� OFFICE OF ��Oy st�ac � O0 COMMUNITY DEVELOPMENT AND SERVICES 30 School Street « North Andover,Massachusetts 01845 9t� WILLIAM J. SCOTT SS^CHUS� Director July 23, 1997 Mr. and Mrs. Richard Scarborough 67 Raleigh Tavern Lane North Andover, MA 01845 RE: SEPTIC REPAIR ISSUES @ #67 Raleigh Tavern Lane. Dear Mr. and Mrs. Scarborough: It is the understanding of this Department that you are currently working with the Board of Health in resolving outstanding issues associated with a failed septic system at the above referenced property. As you may recall, I met with you sometime last year when exploratory testing was being performed on the lot; at that time I informed you that upon receipt of a plan approved by the Board of Health I could then advise you as to what(if any) permits you would need from the North Andover Conservation Commission (NACC). You did not contact this Department until just a few weeks ago and at that time no plan was submitted. Recently, a plan was forwarded to this Department from Sue Ford of the Board of Health depicting a septic system in front of the existing dwelling and parallel to Raleigh Tavern Lane. Richelle Martin, Conservation Associate, took this plan and performed a site inspection verifying that all work was greater than 100' from the edge of on-site wetland resource areas and therefore not subject to NACC jurisdiction. It is now my understanding that the system as designed may not meet the stringent performance standards of Title V and that alternative locations are again being looked at to the rear of the house and within the 100' Buffer Zone of on-site wetland resource areas. A subsurface sewage disposal system that is to be constructed in accordance with the requirements of 310 CMR 15.00 (Title V) or more stringent local Board of Health requirements, shall be presumed to protect the interests identified in the Massachusetts Wetland Protection Act (MGL C.131 S.40) but only if none of the components of the system is located within a wetland and only if the leachingfacility of said system is set back at least 50 feet horizontally from the boundary of said areas, as required by Title V, or a greater distance as may be required by more stringent local ordinances, by- law or regulation. CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 This presumption, however, shall apply only to impacts of the discharge from a sewage disposal system, and not to the impacts from construction of that system, such as erosion and siltation from the excavation, placement of fill, or removal of vegetation. The setback distance specified above shall not be required for the renovation or replacement of septic systems,however,in accordance with the local wetland ByLaw the NACC will not likely permit any disturbance within 25' of a wetland. Construction to the rear of the existing dwelling will warrant a review by the NACC incorporating either a Request for Determination of Applicability or Notice of Intent permit application. This is dependent on the nature of construction and proximity to wetlands. Upon receipt of a final plan approved by the Board of Health please contact this Department so that we may advise you accordingly and avoid unnecessary delays with the permit review process. If you have any questions or concerns please do not hesitate to contact me. Sincerely, Michael D. Ho and Conservation Administrator . Cc: BOH NACC Richelle Martin,Conservation Associate William Scott,Director CD&S Bill Dufresne : Commonwealth of Massachusetts RECW'0,'2[) City/Town of . System Pumping.Record Form 4 TOWN OF NORTH ANDOVER SV• HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be'used, but the information-must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted,to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of house, Left/Right rear of housett rig s e of house Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Un er ec . Address City/rown State - Zip Code 2. System Owner. �('*Nr Name* Address(f different from location) Citylrown State6? 7_09r7z de f Telephone Number `-� 3 1 ` .B. Pumping Record . 1. Date of Pumping Date 2. Quantity Pumped: Gallons ; 3. Type-of s stem: yp y ❑ Cesspool(s) eptic Tank ❑ Tight Tank ! ❑ Other(describe): 4. Effluent Tee Filter present? 4<s ❑ No If yes, was it cleaned? es ❑ No, ' 5. Condition of System: • n /gyp, ".tel 6.. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. L"!L"OS-V re contents were disposed: LowellWaste Water Sign a it HaulerU Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1