Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 67 WHITE BIRCH LANE 4/30/2018 (2)
N QOO V7 QJ r r I MAP # LOT PARCEL # _ STREETf!MaC_._.....:`."l CONSTRUCTI.ONAP _OVAL HAS PLAN REVIEW FEE BEEN PAID? J YES NO PLAN APPROVAL:DATE o� /�APP. BY._,_�,__ DESIGNER: L.F//�I�T/�/V5�/1� PLAN DATE, - CONDITIONS WATER SUPPLY: WELL WELL PERMIT DRILLER._..._____.__.....-.--.--..._.__.._..._._. ____._.._......_............. WELL TESTS: CHEMICAL DA I E APPROVED ... . .... BACTERIA- I. DA I E f1PPROVED BACTERIA II �DA T"E APPROVED. COMMENTS: d-T�56;eVG 6JA767�e FORM U APPROVALS APPROVAL TO ISSUE . YES NO DATE ISSUED �---BY __..._.._— CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YE NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YE NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: MORTtti T1 4o Town of North Andover �`'• '' HEALTH DEPARTMENT ,SSACMUSt4 CHECK #: l— 0 DATE: 9.f 9- 1�,,, LOCATION'-t�n Ii ,�W &(r � 1(t*1� 1 1� �l H/O NAME: CONTRACTOR NAME:, T_yRe 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ` Title 5 Report $T V ❑ Other: (Indicate) $- Vr) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts ` W Title 5 Official Inspection Form NNIGRNV° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 67 White Birch lane TOWN OF NORTH ANDO Property Address HEALTH Jane Betty Owner Owner's Name information is North Andover Ma 01886 June 11 2015 required for every , page. City/Town State Zip Code Date of Inspection G 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor - do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive � Company Name 58 South Kimball street Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 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 ❑ Neejs Further Evaluation by the Local Approving Authority Signature Date Thp 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 4 2 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty Owner's Name North Andover Ma 01886 June 11,2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 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: recommended removal of garbage disposal. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty Owner's Name North Andover City/Town B. Certification (cont.) nna niRRA oiaic Llt! ,uuC June 11,2015 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is North Andover Ma 01886 June 11 2015 required for 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty No Owner Owner's Name ❑ the system is within 400 feet of a surface drinking water supply information is required for every North Andover ❑ Ma 01886 June 11 2015 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 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 • 3/13 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 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is required for every North Andover Ma 01886 page. City/Town State Zip Code C. Checklist June 11,2015 Date of Inspection 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): 660 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 �. Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is required for every North Andover Ma 01886 June 11 2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? 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 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No Occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 67 White Birch lane D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State 01886 June 11,2015 Zip Code Date of Inspection General Information Stewarts Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Tank is 1500 gallons gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Property Address Jane Betty Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State 01886 June 11,2015 Zip Code Date of Inspection General Information Stewarts Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Tank is 1500 gallons gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is required for every North Andover Ma 01886 June 11 2015 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: 29 vears Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 60"feet 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): Depth below grade: Material of construction: ® concrete ❑ metal 12" B.T.G. feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts a - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) State Zip Code 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 33" 0 6" 14.5 June 11,2015 Date of Inspection How were dimensions determined? Tape measure & 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.): Both Baffles good no leakage liquid levels good Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts u u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is North Andover required for every page. City/Town Ma 01886 June 11,2015 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 White Birch lane Property Address Jane Betty Owner's Name North Andover City/Town D. System Information (cont.) Ma 01886 June 11,2015 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 9 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.): Equal Dist no leakage no solids carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM 67 White Birch lane D. System Information (cont.) State Zip Code June 11,2015 Date of Inspection Type: Property Address Jane Betty Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) State Zip Code June 11,2015 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 2-42' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure no damp soils no ponding. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins - 3/13 ❑ 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 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is North Andover required for every page. CityrFown D. System Information (cont.) Ma 01886 June 11,2015 State 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 condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I, , 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is North Andover required for every page. Cityrrown nnn niQQa June 11,2015 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 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts N u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.M 67 White Birch lane Property Address Jane Betty Owner Owner's Name information is required for every North Andover Ma 01886 June 11 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: None @ 10' 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: 3-23-86 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Pulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Taken from design plan around water at elevation 117.6 bottom of bed at elevation 122.0 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Insp Subsurface Sewage Disposal System Fo 67 White Birch lane 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 ection Form rm - Not for Voluntary Assessments Property Address Jane Betty Owner Owner's Name information is required for every North Andover Ma 01886 June 11 2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 'o -Ift U. ELEVA TIONS. DESIGN I AS—BUILT 1 INV. OF PIPE OUT OF HOUSE 125.95 126.52 INV. OF PIPE AT SEPTIC TANK INLET 125.45 123.44 INV. OF PIPE AT SEPTIC TANK OUTLET 125.2 125.25 INV. OF PIPE AT D—BOX INLET 124.4 125.21 INV. OF PIPE AT D—BOX OUTLET 124.23 125.00 OF DISTRIBUTION PIPE 124.25 FINV.EATEBEND D OF DISTRIBUTION PIPE ,/1 124 124.01 INV. AT END OF DISTRIBUTION PIPE 1121124 124.07 I HEREBY CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THIS DISPOSAL SYSTEM AND THAT THE CONSTRUCTION AND FINAL GRADING HAS BEEN IN ACCORDANCE WITH THE DESIGNER'S INTENT AND THAT THE MATERIALS USED CONFORM TO THE PLAN SPECIFICATIONS AND 310 CMR 15.00. NOTE. )41S PLAN IS NOT A WARRANTY OF THE SYSTEM BUT A VERIFICATION OF THE LOCATIONS OF THE EXISTING STRUCTURES. AS BUILT PLAN 4�7 OF SUBSURFACE DISPOSAL SYSTEM IN NORTH ANDOVER, ASIA. PREPARED FOR. WHITE BIRCH CONSTRUCTION SCALE: 1" = 20' DATE: SEPT 5, 1994 CHRIS TIA NSEN &SERGI PROFLAND SURVEYORSEERS 160 SUMMER ST. HAVERHILL,MA. 01830 TEL. 508-373-0310 Qc 1994 BY CHR/STIANSEN & SERGI INC. LOT LOT 61 AREA -55452 S.F. oh.� �Z FO LINDA TION ' 9• EL E V. = 130.9 181.5' Commonwealth of Massachusetts City/-rown of N O ."Over a W° System Pumping Record Form 4 4'M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. 2. rcaan V) 0C P).1 Vy - I I I IIu City/Town System Owner: Name Address (if different from location) City/Town RECEIVE® I11t1 1 r,20..; r To' ,'N rf` tJorlr{a ANDOVER AF,,TF0ENT Zip Code CkA(7\ State Telephone Number Zip Code B. Pumping Record Sno1. Date of Pumping5'/11//5 oat 2. Quantity Pumped: eau/s 3. Type of system: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Irt's Septo5efvice ny if yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 7. LocatiotYwhere contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Location No. �P,30 � Date ) -30- o Check # 15 12- 3 TOWN OF NORTH ANDOVER a Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspecto r " TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMrrOLISH A ONE OR TWO FAMILY DWELLING x €' s� R+' Y�'lalr ,,'?• -Y , "cilli a �,r •r e tw'+ # - S xT"Yx �' .r,«i.T:..-.. 2 BUILDING PERMIT NUMBER: �+-- DATE ISSUED: J SIGNATURE: XlVrC,-- Buildin Commissioner/IEEQEtor oCBuildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ,UX/ e B14AC� 141U -r �p 9'�Z Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. blood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service 0/'Y--� F3 —0/-)") Signature Telephone 2.2 Owner of Record: dme Prin _. Address for Service: r na re Telephone SECTI N $ - CONSTRUCTION SER CES 3.1 LiV Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition 0 Accessory Bldg. Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: \ro r --e SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant UFICIA. USE (1fNLYF :; 1. Building DQQr , r (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical (HVAC)�- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII,DING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FUKIVI U LU 1 XELEAS )h r OK[yi f 1 -�) INS TRUCTIONS' This forth is used to verify that allnecessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the �2�c_ wt w1 applicant and or landowner from compliance with any applicable requirements. Is.■s.■..s■.s■■es■■..s.....Woman" sss•■....■■. Bonn . Boom ....... woman ado s.swas APPLICANT PHONE ASSESSORS MAP NUMBER LOT NUMBER a SUBDIVISION I II LOT NUMBER STREET r(r c h L� STREET NUMBER 617 OFFICIAL USE ONLY RECOI`CvffiNDATIONS OF TOWN AGENTS DATE APPROVED CONSMVAnON ADMMSTRATOR DATE REJECTED coNn�Nls ! v VV DATE APPROVED_ /I 7 Z6) Wr,, k. j DATE REJECTED DATE APPROVED - FOOD INSPECTOR - HFALTH H H } DATE REJECTED G�//SCJ DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COMM -tm PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMNIENI'S RECENED BY BUILDING INSPECTOR DATE Cl) m U) 0 m CA -v 0Z CD O ar O O CL =. .0 O o v a� Q CD 0 E O ca o H CD 0 d C7 CD O r* CD -�v CD _a y. CD CO) -0 O •HOQ H ao a� m CA CD n m C) 7 p io yFa0 54 .. CD -i G H G y _ o � ?m m O > > m G n O N• C9 : 7 pp �o o � ay a ��s m to o a^.� .O VJ 0 CD H to CD 0C f H � CLQ d C CL 00 H ` UCD 4C :t ''^^ " m y V J N N m m 2�� o = m .�all o� : v zCD ,. cn 0 y �r D C i►: t.; CD . o VJ C CO) CD a� ncC =s: cn CDa o=� o 0 0 C ITI d O r 77 O O 0 z O 0 P z n Q Q O i H 0 0 c FOUNDATION LOCATION PLAN CLIENT: SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER,MA. SCALE:1 "=40' DAT£:6/7/94 CHRISTIANSEN &SERGI P'°°LAND SUREY RS £ 160 SUMMER Sr. HAVERHIL4MA. 01830 TEL 508-373-0310 © 1994 BY CHRISTIANSEN # SERGI INC. 111 ANE I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS /N EFFECT WHEN CONSTRUCTED. (THIS CEmneAnom DOES NOT CONSIDER ANY OTTIER RESTRIdnONS SUCH AS COYEKANT�WErLANDS;F"M04M ORDERS OF CONDIMAMETGj THIS ORAWING SHALL NOT BE USED BY THE QUEM FOR ANY PURPOSE OTHER 7HAN THAT OUTLINED ABOVE;EXCEPT WITH THE WRITTEN PERWSWON OF CHRISTEINSEN R SERC! INa FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHR/STGINSEN & SERC/ INC AND ANY UNAUTTIOR= USE LS PRWl8nED,OR/STL WN # SERGI TAKES NO R£SP0NS,91WY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY /NFOR-. MA770M CONTAINED HEREON. � a � ION SCALED N SYMCIVRE AFLOOD HAZARD ZONE SHOWN AS SHOWN ON Mo FLOOD NSURANCE RATE MAP. COMMUNITY N0- 250098 00050 DATE. 612193 DWG.N0.:93067016 11 SJ f O i J I • �I N tn K1 V� it m ,;. Ln �0 m N N p �- 2 � ? vo N N CN h N N N N O N p �Q�� JJ jZWi mU Pn °� `'r� o • N �O kz �nr,� Q� M z� o pJi(3 i �v) Locto rr,^, ` Nt1i �3 O ^� N vi N 'i N N N N ti�3O i �W O�ZUU pLLJ 15 Q O~ ,, c� Q :zQ Q W j°QQ^ 3Z J�4 20 Wv 0 2 Lij J Q � W� y J J O ►, O m \ W Z� p psE` � ~O U r` �� � 2 p l Ly 44 ~�tnz0 b J �Z m vJ LZ v 1 to/�y�J to ° ti Q tj Q J Q Z ,. = N y ~ Q� rJb—�Q4���y J� SVT �11 Z ` ., W���zU Q. 4 W 2 2 UOQZO \ m O O O O O Q Q (� Q ca-,Lo(.5 W \ � CIC jZV f 1. A SJ f O i J I • �I N tn K1 V� it m ,;. Ln �0 �- FORM U Lu d RELEASE F ORM INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from rds and Departments having jurisdiction have been obtained. This does not relieve the Wt wr applicant and' or landowner from compliance with any applicable requirements. �■■.r.■■■.r.�..r.rr.■...■rrrrr�,■torr■■r■■■■■■r■■.■■■■■■■■■■■rr■rrpr■s■prrrrr■nrr APPLICANT �) ®3to l r PHONE b `h D� Q / ASSESSORS MAP NUMBER "` LOT NUMBER SUBDIVISION ( lit) LOTNUMBER U..ESTREET( r C- �t STREET NumBER 6 OFFICIAL USE ONLY .............................'er■..............■.rre■.■..r......r..r...rs..■■. RECONp,fENDATIONS OF TOWN AGENTS room rre.r......s.■r......... owes r■one nouns* means ■■..rrss.r...rs..rr....r... CONSERVATIONADM MSTRATOR COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED ........ .. ------- -- —D ... — ._ se es .. ------------ --- -- — _ATE APPROVED FOOD INSPECTOR TH f/ SEPTIC INSPECTOR — HEALTH CONRY ENTS PUBLIC WORKS — SEWER / WATER CONNECTIONS DRIVEWAY PERMTT FIRE DEPARTMENT COMI ffNTS RECEIVED BY BUILDING INSPECTOR DATE REJECTED DATE APPROVED v v DATE REJECTED DATE APPROVED DATE REJECTED FOUNDATION LOCATION PLAN CUENT: SCOTT CONSTRUCTION TH/S CERTIMAT/ON is MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER,MA. SCALE. -I"=40' DATE:6/7/94 CHRISTIANSEN &SERGI P' LAND SURA � E 160 SUMMER ST. IAVERHIL4MA. 01830 TFL 308-373-0310 Q 1994 BY CHW41ANSEN & SERCI INC. l SANE I CERnFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS m THE HORIZONTAL SETBACK REOU/REMEMS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN DrrECT WHEN CONSMUCTiO. REHM CEIVINS AT AS SNOT CONSIDER ANY OTHER ORDERS OF CONOMONS„E/M MNOS,fASEMENT.S', THIS DRAWING SHALL NOT BE USED BY THE C" FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE.EXCrPr WITH THE WRITTEN PER IWON Of CNNSILWSEN R SEROI Na FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRSAANSEN # SERC/ M AND ANY UNAUTHORIZED USE LS PR0H/B/TED.CNRI37IAN5EM & SM TAKES NO RESPONSIBILITY Fi vG+vLvv2 V "IV %/!vl/VI V oU W Zk aZi Q W o Q Qw- W Z O 44 i o O Q- o j F. � Q z o m aa -.- z 0 m O J m h N N N N N N o � N N - .p N N W Zk aZi Q W o Q Qw- W Z O 44 i o O Q- o j F. � Q z o m aa -.- z 0 m O Q Q Q Q O O O O O %Q. � CL Q_ � � m LZIJ W W 0 0 0 0 Q Q Q 2 2 z z z o z 2 W Zk aZi Q W o Q Qw- W Z O 44 i o O Q- o j F. � Q z o m aa -.- z 0 m O Q Q Q Q O O O O O %Q. � CL Q_ � � m LZIJ W W 0 0 0 0 Q Q Q 2 2 z z z Z z 2 �2 O� �2WZ ct cl 030 V O LQ LQ Q. Q W O ��J Z�?�V Q�.mWM tiO 2 �QZQQ �ocz WQ.z z 0 °�QQ C13 (1) W~QWW z J • ` O h� O X I � Q LO 0 00 � oQ QL � J Y FORM U - LOT RELEASE FORM INSTRUC NS This form is used to verify that all necessary approvals/permits from Boards and epaVents having jurisdiction have been obtained. This does not relieve the applican ,ndlandowner from compliance with any applicable or requirements. *** ******APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT �('� �. •.(� P t L PHONE (�C -Z' LOCATION: Assessor's Map Number! PARCEL SUBDIVISION1j t�� 31 /e LOT (S) STREET 4-)67,7.c i3jqA ST. NUMBER !� *�►*** k,t**********************************OFFICIAL USE ONLY***************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINI§TRATOR COMMENTS TOWN PLANNER I� COMMENTS FOOD INSP�MR-HEALTH /SE,PTIC ECTOR-HEAL DATE APPROVED DATE REJECTED_ DATE �PPROVED DATE REJECTED - DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED �— COMMENT S l�-o v S c7 S PUBLIC WORKS - SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE C-) 0 z cn m D O 7 CO) CDz CD O CL r d d O � D O Zq �v CD CL cr CD o ff .. .. d O O to CD CD CO) CD 0 L! w Cl) CD O CD a y, CD CA U: GO z i c ?� m 2 O • rn � CS y 0 5. CD ,o to S m nC) C y 0 CL � m o, �••► ^' CD o' T �a�n o y CD O � �COD � CD CD > Oo ,o CS � ..w O O O y C7 �oo a C N CL n o ca CL ca o CD - CD c CD CD CL to =CDCD O_ p) CL O' CO) _ C CL 7 _ y � CD CA )► C CO CD Cv y CO y (00 CD� 0 O O CD o. �9 CO) ...r 'O O On CD n� CD y ` '" W o O CS O �C CCD C � y Z I r � o ^; . a jrh, ccbo�. Z c = • W„�=m: cn C/)w 0 " 'C+ rt � 111:1 O � G w :v�� y < C M I y C n my � � 0 G w �Z C n c x � cpCD cn r �Nl\ CO)tfl x omq 0 9 0 Omh t NORTH 1 Q 4Tl�D yep tiQ 10- 9 SSACHUSo- Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 ,, , DISPOSAL WORKS CONSTRUCTION PERMIT Applicant rYlL" LA^- NAME ADDRESS TELEPHONE Site Location L0 kaL LA ZIN Permission is hereby granted to Construct {--'or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. rD Fee CHAIRMAN, BOARD OF HEALTH D.W.C. No. Q W v s CLIENT: FOUNDATION LOCATION PLAN SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER.W. SCALE. -I"=40' DATE:617194 CHRISTIANSEN &SERGI 160 SUMMER Sr. HAVERHILL.MA. OM3" TEL 308-373-Wf" Q 1994 BY CHRISTMNS£N & SERGI INC 11 ANE I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO TIE HOR20NTAL SETBACK REOUIREM£NTS OF THE LOCAL ,4PRLC,0U ZONING BY-LAWS /N EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS. WETLANOS.EASEMENTS. ORDERS OF CONDITWNUM) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTUNED ABOVE.EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTUNSEN & SERGI /NG FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISIIANSEN & SEMI UVC, AND ANY UNAUTHORIZED USE IS PROHlaffOXHAYSMAWN # SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INf'OR- MATION CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. COMMUNITY NO.: 230098 OOOSC 441£:6/2/93 DWG.NO.:93067016 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section****************'** APPLICANT: ,J C Phone LOCATION: Assessor's Map Number Subdivision `� I AJt Street RECO NDATIONS OF TOWN AGENTS: i�' Conservation A ministrator Comments Town Planner Comments Food Inspector -Health Sep lc Inspector -Health Comments Parcel Lot (s) St. Number Use Only**********************y Date Approved Date Rejected Public Wor}:s - sewer water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved lckq- Date Rejected Received by Building Inspector Date ,AORTN 0 CHU Town of North Andover, Massachusetts BOARD OF HEALTH Form No.2 Ool' 14S-1Qa3 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant I M(")'elx-ewl Test No. Location- 4147— /5 Reference Plans and Specs. Ile- /-1 4 Z- - ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIRMAN, BOARD OF HEALTH SiteSystem Permit No. � oZ ? DATE—&/Q1//. /�� 5 Sheet of l BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW j FEE Y' (O PERMIT # a Z DATE RECEIVED APPLICANT J > M (91'/46AI ASSESSOR'S MAP ADDRESS ENGINEER ADDRESS PLAN DATE AUG. /91� �3 CONDITIONS OF APPROVAL: APPROVED DISAPPROVED �V /) M/N/MUM DG PARCEL # LOT # to STREET # 4.0 REVISION DATE PLAN REVIEW CHECKLIST ADDRESS,Z T,, ENGINEER GENERAL 3 COPIES '� STAMP `� LOCUS L--' NORTH ARROW �� SCALE L/ CONTOURS (� PROFILE SECTION ✓ BENCHMARK t,-' SOIL & FERC INFO ELEVATIONS WETS. DISCLAIMER 1,,� WELLS & WETLANDS WATERSHED?A/0 DRIVEWAY`fj(Elev) WATER LINE FDN DRAIN SCH40 ✓/ TESTS CURRENT? ZM 9/- 9/z SEPTIC TANK MIN 1500G.__L,,-' .17 INVERT DROP GARB. GRINDER (+200% EDF) 25' TO CELLAR z/ MANHOLE TO GRADE ELEV GW —` D -BOX SIZE # LINES o'?-- FIRST 2' LEVEL STATEMENT INLET /d� - OUTLET 04,23 = - , %Z ( 2" OR .17 FT) TEE REQ' D? Vo LEACHING RESERVE AREA(/ 4' FROM PRIMARY? 61-' 100' TO WETLANDS 2% SLOPE 100' TO WELLS 35' TO FND & INTRCPTR DRAINS e-� 4' TO S.H.GW 325' TO SURFACE H2O SUPP t/' 4' PERM. SOIL BELOW FACILITY e-,� MIN 12" COVER -------FILL? (25' if above natural elev; 101if below) BREAKOUT MET? --- TRENCHES MIN 660 gpd &/ SLOPE (min .005 or 6"/1001) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61),,y IS RESERVE BETWEEN TTRENCHES?/0IN FILL? MUST BE 10' MIN. 4" PEA STONE? tl/ BOT f by X LDNGJ � I + SIDE &36X LDNG�O� = TOT (L x W x #) (G/ft2) (DxLx2x#) UER MASSACHUSETTS-:." ---�lt'DEP has provided 04.'form for U60 by IOC61 Boards of He' 0 sub alth, b �nl4id to the .*81'Board of Health or other appyiTy �nqj A., Facility 9ri, I n, f'ation SysteSystemUon:*,".' 7y.f%U* UQ out Loca Wy the W key Address to move your :: LIM P ksY, m Nun' W .... ..... . The System Pumping Recon rr.;, MAR 10 2008 OF Ni) TH ANDOVER --ZZI State I ZipCode 4dim (V Marent A fronic4 �Qn) 77e Ll T0100we Number P 14 2, QuantJty Pumped: yp,Q q,5yjteft:,:--,.❑ Cesspool($) SeptIc'Tank C1 Tight 'S Tank 4,0ther 4. W'Ot T66 F16 P ED ❑'Yes. 0 No If yes, was It cleaned? C3 Yes CD No S6 If -ds r. Number SYCOM Pumping Record - p;ye I c! ! TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: --� SYSTEM OWNER OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) ri N. ATcA� DATE OF PUMPING:ZO QUANTITY PUMPEDy GALLONS CESSPOOL: NO 4ES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE v EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER uYSTEM PUMPLL BY. COMMENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN)