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Home My WebLink AboutMiscellaneous - 7 FULLER MEADOW ROAD 4/30/2018 7 FULLER MEADOW ROAD toad J 210/104.D-0129-0000.0 — L — I� `I 1 4 4 Commonwealth of Massachusetts City/Town of . System Pumping-Record Form 4 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 IJqh#front of h e>Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address 1-7 &Lg�y��, Cityfrown State Zip Code 2. System Owner. RECEIVED Hcx- Name' MAY I R 2Q15 TOWN OF NORTH ANDOVER Address(if different from location) MALI F1 WEPARTENT Citylrown ' - State � _ zi cc Telephone Number � B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Canons 4 3. Type-of s stem: y- ❑ Cesspool(s) - eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No, 5. Conditio of stem: GSA- - V\ 6: System Pumped By.- Nell y:Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Location where contents-were disposed: L Lowell Waste Water Sign Haul Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 ,4 ' sw.�Tt�n°res North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 7 Fuller Meadow Road MAP: 104.D LOT: 0129 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box and pipe to tank, outlet tee: 10/16/13 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Q Speed levelers provided (not required) Comments: • • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 10/16/13 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D-box, pipe to tank, outlet tee By: Todd Bateson At: 7 Fuller Meadow Road Map 104.D Lot 0129 North Andover, MA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. U �. Mi Grant ' Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts FHEALTH BIVD City/Town of System Pumping Record OCT 2n1� Form ,4, TH ANDOVER r PARTMENT 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/ Qh front of ho , Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address 4u A,�2�-AAA- W � City/Town State Zip Code 2. System Owner: Name Address(if different from location) Citylrown State Zi Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes El'No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition�pf$Ystem: v C.moltiCZA 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: 1-S. Lowell Waste Water Signitufe ct Haule Date t5form4.doc•06/03 System Pumping Recons•Page 1 of 1 6WAJ-- loll • �� n{ ,: Commonwealth of Massachusetts Map-Block-Lot 104.D0129 BOARD OF HEALTH Perm - Permit No------------ • Pt North Andover -BHP-2013-0980------------- ----- ---- P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted -Bates-on Ent -------------------------------------------------------------------------------------------------- pvl to(Repair)an Individual Sewage Disposal System. 1_)LJk It PlINQ at No 7 FULLER MEADOW ROAD ------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. B •' '—, 22�ob -013--- ob fin' ------------ -------------- --- Issued On: Oct-15-2013 BOARD OF HEALTH Of,MORTN 6610 O = Town of North Andover `+�'••;; o:. �' HEALTH DEPARTMENT ,SSACMUSft CHECK#: DATE: LOCATION: �... H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTICSystems : ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ p Septic Disposal Works Construction(DWC) $_QS Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer • .Fnia Commonwealth of Massachusetts Map-Block-Lot m... , 104.D0129 BOARD OF HEALTH Permit No North Andover -BHP-2013-0980---------------- ------ FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bate-son-Ent ----------------1�J -- -----�----------------------- ---------------------------------- II r- to(Repair)an Individual Sewage Disposal System. b y + - �"� WL � 6Wtk at No 7 FULLER MEADOW ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2013-098 Dated October-15-,-2-0-13 --------------- ------------------------------- - - --------- Issued On:Oct-15-2013 pp-��- ------------------------------ I ARD OF 4EALT L._----• r Application for Septic Disposal System Id - `l- f 3 Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 a z5 00-comp ene�t Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* _ only the tab key pair to move your eor replace an existing system component—What? — �1_ cursor-do not use the return A. Facility Information key. Ei.L l(z� /-e.4�d.✓ Address or Lot# _ _ - tab C+tylTown 2.-*TYPE OF SEPTIC SYSTEM*: O10T '15 2013 ➢ ❑ Pump ravity(choose one) ***If pump sys , attach copy of electrical permit to application*** +'�; l: EA ➢ LKConventional System (pipe and stone system) ➢ ❑Infiltrator or Biddiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information 4st../�' Name Q Address(if different from above) City/Town State Zip Code �o 7A4 lI q Telephone Number 3. Installer Information 7-7;_dx9_ Name Name of Company 111 ARGILLA ROAD'INC. A A-eq. ANDOVE SAA 01 a1 A Address City/Town State Zip Code Telephone Number(Cell Phone#ifpossible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 ACApplication for Septic Disposal System TODAY S DATE Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 $250.00-Full Repair $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of th, the installed system is not approved. Name Date Application Ap v By: (Board of Health Representative) Name Date Application Disapilroved for the following reasons: ForOffice Use Only: _..T.�.._._._ �..m...�...�...._._.._��...ro...�.��.._,...._,.�.__._.�M�....�..m. Z Fee Attached? Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump 3sv tem? Ifso,Attach copy ofElectrical Permit Yes No 4. Reviewed approvalletter, all paperwork received. Yes No MISSing:' 5. Foundation As-Built. (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPxIC-S.Y.STEM. -ER•PRGJEC."I'MANNA EmENT OBLIGATIONS for the construction fdr:the septic systern-for,the•property at As tl e.North Andover.licansed sistaIler / Lt(L � For pinna by (Addresd of septic system) r) Relative to the.application of �s�N And dated ' (in'staller's same) r a ae . Dated With revisions dated -TI o s date) (Last evised date) I understand the following obligations fur management of-this project: 1. As the installer,I am.obligated to obtain.alI perquts and Board ofHealth approved plans,p-dox to performing any work ons site.. 1 must have the abroved glans and the permit:on site when=work is r• bCnj done. • 2. As tie installer;•I must:'•call-for-any and ill;inspictions: I£homeowner,contractor,.project manager,or any other person not associated with my company schedules-an inspection and the system is not ready,then item three shall.ke:applicable. As the installer,I stn rtqunrcd to.have.the Aec,�s&sty work eQm�pieted'prior to the.applicable inspections as indica.ted b. l. •T wY, -h;ridO_ft•and th t r�t;ii�� g�p.ecti },without completion:of the-items in accordance .eo ,mth j1de of 14calth Rj6&s• Y&e6ut a ko:Ob fine being.levied'apki :me..6d/ob. r Bo't oYritSf l ed: ienerill' this-is thc`fits . 1 ups eoflom�taless:there is a-retaynng wall,which ' should•be dei ie< st: Theldstal rX.-Musttrqutst flit*specddsl but does•riot have to be present:' . .'.b. Fin 4 : Cq } }c>`i'oii.IttspecdorY—Engineer miis't first�do then inspection for elevations;firs,etc. As-built of verbal OK dor a-mail to:hea7t11dpn to 0 o�handover.coml:from the engineer must be submitted to':the.Board'ofHealth.,a.et:whieli�installer•calls for.an inspection time. Installer must be present for fl*.inspection, �ith'a pump sy$ttm,all clectri6al work:xnust:be ready and able to cause putt�p.to work arid.aLum'•to function.. c. :Fin :Grade—installer must tequest'inspectionwhen X11 gradng'is'complete., Installer not have to be on=site. ' 4. As-the installer,'I unddstand that only I day perform the Vofk'(other than ihVle e-ccavatron)and'l ani required io complete tie•installatibn of the system iclentffied in the attached application for installation understand:that work•done bY.otiers ui i'ceiise� o uistall tcptac',wtems•in Nardi Andover Cali constinite reasons for dei ial'of tht•system and/or S:voca-oil-6r SuIApen. ion Qfrnv jeense•to operate in the Town f —•�. .. . North Andover.-Si0iii6cant fnies to 2H persIve greo 5.. As the.instller,-I uaderstartcl that.I�nti§t`ne on-size during th .perfaima'nce of the-fog owing construction, steps:.. a: Detemination'that.theproperefevatiorr of the ezeavatson bas been reached - A Inspeetlon ofthe sand and mve'to be used. c. Final inspecdorr by Boarol of.Uealth staffor consultant. d. Installation.•oftank,D-Rom pipes,stone, vent,pump chamber,retairu'ffand other wall COM ponents. 6. As thy installer::I zi6rstand that I:=s6I*rer ,cpousibl4 for the installation of ihesiftem as per the appy 'g=j, No ins�i tions by tielhomt�Q er gcnP*�i confra.,. or a}�y.o h r.persons shy absolve me fes• 's ob ' tion. Undersigned Iricenaed Scptic.Iastallex: : (t'oday's IAatej of 4Mo eT:�y 66112 •- s s r Town of North Andover .: HEALTH DEPARTMENT �ss u CHECK#: DATE: V LOCATION: r H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $��V J ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer r , Commonwealth of Massachusetts Y d Title 5 Official Inspection Form L C" 1-513 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information W1� forms on the OCT 15 Z3, computer,use 1. Inspector: only the tab key to move your Neil J. Bateson rowN LT t Dr rl r.iv,eN rR cursor-do not HEALTH,D�PAF�7iv�rl�iT use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 fBMd/0 Cityrrown State Zip Code 978-475-4786 S115 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 ❑ Need§i Further Evaluation by the Local Approving Authority ty 10/8/2013 Inspector's tignature V 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. � . M t5ins•3/13 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 0 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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: 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 Forth:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 , Commonwealth of Massachusetts urTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. CityrFown 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: Outlet tee in septic tank, broken outlet pipe&d-box needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® 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 Y2 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 Foam-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Fonn: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 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 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): 600 t5ins•3113 Title 5 Official Inspection ion Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owners Name information is required for North Andover MA 01845 10/8/2013 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: July 5, 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 ficial Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. Cityrrown 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: Pumped 2009,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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 29 years old, 7/26/1984, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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.): 4"cast iron through wall to septic tank, 3" PVC in house no leaks visible Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' Sludge depth: 2" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °yt 7 Fuller Meadow Road Property Address Bruce Masek Owner Owners Name information is required for North.Andover MA 01845 10/8/2013 every page. Cityrrown 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 26" Scum thickness ti Distance from top of scum to top of outlet tee or baffle 8.. Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee corroded off, needs to be replaced. Outlet pipe to d-box broken, needs to be replaced. Liquid level at outlet invert. No evidence of leakage. 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•3113 Title 5 Official Inspection ion Form:Subsurface S swage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy< 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name informationis North Andover required wirfor for MA 01845 10/8/2013 every page. Citylrown 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: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owners Name informationis North Andover required wirfor for MA 01'.845 1.0/8/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box has corrosion holes, needs to be replaced. Liquid level below all outlet pipes. Evidence of leakage. No evidence of 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 Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 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: ® leaching fields number, dimensions: 1 field 20'x 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok.Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 13 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owners Name information is required for North Andover MA 01845 10/8/2013 every page. Citylrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. Cityrrown 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 tv A- Ao '�a�31t1 L4 117 t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 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: 4 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. 5/19/1983 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan Checked with local excavators, - ❑ ca ators, installers attach documentation ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Fuller Meadow Road Property Address Bruce Masek Owner Owner's Name information is required for North Andover MA 01845 10/8/2013 every page. Citylrown 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 Town of North Andover Test V Tax Map # 210-104.D-0129-0000.0 Parcel Id 16812 7 FULLER MEADOW ROA MASEK, BRUCE J 7 FULLER MEADOW ROAD N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.55 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until MASEK,BRUCE J Payor 7 FULLER MEADOW ROAD N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18712.0-7 FULLER MEADOW ROA Last Billing Date 7/12/2013 3160280 03 Cycle 03 Active UB Services Maint. Account No.3160280 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 53.20 /1 UB Meter Maintenance Account No.3160280 Serial No Status Location Brand Type Size YTD Cons 32945201 a Active 00 b Badger w Water 0.63 0.63 601 Date Reading Code Consumption Posted Date Variance 6/10/2013 855 a Actual 14 7/24/2013 -13% 3/6/2013 841 a Actual 15 4/22/2013 -22% 12/7/2012 826 aActual 20 1/9/2013 -71% 9/5/2012 806 a Actual 68 10/15/2012 274% 6/6/2012 738 a Actual 18 7/16/2012 11% 3/8/2012 720 a Actual 17 4/14/2012 -15% 12/5/2011 703 a Actual 19 1/17/2012 -72% 9/7/2011 684 a Actual 72 10/13/2011 268% 6/6/2011 612 a Actual 20 7/20/2011 14% 3/3/2011 592 a Actual 16 4/13/2011 3% 12/6/2010 576 aActual 16 1/12/2011 -83% 9/7/2010 560 a Actual 103 10/15/2010 436% 6/3/2010 457 a Actual 18 7/15/2010 17% 3/5/2010 439 a Actual 15 4/14/2010 -10% 12/7/2009 424 a Actual 18 1/12/2010 -46% 9/3/2009 406 a Actual 32 10/15/2009 74% 6/3/2009 374 a Actual 17 7/20/2009 7% 3/10/2009 357 a Actual 18 4/29/2009 -15% 12/4/2008 339 a Actual 20 1/20/2009 -58% 9/4/2008 319 a Actual 48 10/10/2008 176% 6/4/2008 271 a Actual 17 7/16/2008 1% Trouble Code:03 3/6/2008 254 a Actual 17 4/11/2008 -8% 12/6/2007 237 a Actual 17 1/22/2008 -76% 9/13/2007 220 a Actual 80 10/12/2007 411% 6/12/2007 140 a Actual 16 7/20/2007 -12% 3/9/2007 124 a Actual 18 4/16/2007 -4% 12/5/2006 106 a Actual 18 1/19/2007 -75% 9/6/2006 88 a Actual 69 10/20/2006 336% Commonwealth of Massachusetts nr-CiVa City/Town of System Pumping Record r, 2;39 Form 4 wN TOWN OF Iv.. 'ER HEALTH DEPf.r.�, ._ v T DEP has provided this form for use by local Boards of Healt -"`Other ormf s 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 tq 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 side of house, Right side of house, Left front of hous Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of buil ing. Address t-7 V v City/Town State Zip Code 2. System Owner: Name Address(f different from location) Citylrown State Z" Code � Telephone Number B. Pumping Record _ 1. Date of Pumping Date Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of�System: Vv\, 4z� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water - &2 -� Signature of Hauler DatLi- t5form4.doc-06/03 System Pumping Record•Page 1 of 1 TOWN OF SYSTEM PUMPING RECORD, s r DATE: MAY 2 3 2003 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) a (iki �� b asc_ do� DATE OF PUMPING: "oZ _ O QUANTITY PUMPED : SO GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE Z- EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location va-s e- k -/-7/I�u116--, Date of Pumping: 7// `W Quairiity Pumped:115710 gallons Cesspool: No Yes L:J Septic 'Tank: No Yes System Pumped by: Stewart Sria7,64aed License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspectors a Address ? A AAow,- Rio Title of File Page of Date File Open: Date file closed: Choc Document/Action Title Date of Refer to other Purpose of Document/Action and notes. action Document/ document/ filum• Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Buiiding Departrment Board of Health SEPTIC SISTER North Ano_01er2Ha35. LOT INMALLATICK CHECK LIST '' OOID DATE BISAPPROM EXCAVATICH 01 FAIL 41 / easanst IMAZL CK 1. Distance Tot • no Wetlands b. Drains C.. Well 2. Water Line Location 3. No PVC Pipe }�. Septic Tank - a. _Tees -_hength & To Clean Out Covers. b. Cement Pipe .to Tank Cu Both Sides of Tank 5• Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench no Dimensions b. Stone Depth c: Capped Eads ' d. Clean Double-Washed Stone' 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees r; e. Ceoaent Pipe to Pit - Both Sides !` f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11, As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations ' l e: Water Table Board of E-Mllh SUBSURME DISPOSAL DESIGN CHECK LIST LOT FV116-W4004)+ APPROVED DATE ` DISAPPROVED DATE Provided Reasons: Title V FAIL CK Reg 2.5 Ae submitted plan must show as a minim=: the lot to be served-area,dimensions lot #,abutters location and log deep observation holes-distance to ties location and results percolation tests-distance to ties dssign calculations & calculations shov.*ing required leaching area location and dimensions of system-including reserve area existing and proposed contours g) location any vet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping h surface and subsurface dx-ains vithin 100' of se-.,-age disposal system or disclaimer (i) location any drainage easements 14thin 100' of swage disposal system or disclzir--r-Planner Board files jq) kno= sources of -..ater surply with n 200' of sekage disposal asystem or disclainer-�cati-on--ef xT }proposed sell to serve lot_lOJ!frim leaching facil location of water lines on property-10' from leaching Sacili�location of benchmark drivekays garbage disposalsno PVC to be used in construction profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations nay==m ground tater elevation in area sage disposal system s) plan must be prepared by a Professional min®er or other professional authorized by law to prepare suich plans Reg 6 oe Septic Tanks (a) capacities-150%- of flow., table,- tees, nepth of tees, ap 01 access, pining b) cleanout I � (c) 10' from cellar 1 or inground �.,? - ng pal d} 25' from subsurface drains Reg 10.2 Distribution Faxes (a) slope greater than 0.08 Reg 10.1 D No 4 , : �� e0o r � ~ .SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No Fula (Z- E-tT Lot No Loc/Subdiv. Pland Owner �'QC.O Investigator Observer !'N5P SOIL PROFILE DATES �(�3 1.-)F ev 2.Elev 3.Elev 4.Elev 0 0 S� 2 0 0 1 S 1 Ties Ph Test 2 2 2 2 3 3 3 3 4 42tjE L 4 G E t_ 4 4 T0 1 5 5 2 5 5 6 6 6 6� 7 7 7 7 8 8 8 8 9 9 9 9 10- 10 10 10 Benchmark Location Elevation Datum PERC0;.ATI0N TESTS DATES fir S $3 Pit Number g-i C✓, 2 3 4 Start Saturation Soak-Minutes Z Z Start Drop of 3"-Time Drop of 6"-Time Mons-lst 3" drop Mins.2nd " Drop Percolation 70.00 oc�p i i i r 1 ` r er / f 1 0) O h F } i f ► tr i LOT 51 67,521 6 E ammoms - TOP FND 140.52 "OUSE aJ LE. 138.10 i f{ ST INLET 136.33 G i ST CUA D la0x �� 13C,1,3 135.,55 D 8OX OUTLET 135.55 1 E R D Rqp 135.31 EX 3 ISTING DrtA11�,4C,E t EASEMENT mss* i 1 EASEMENT A C t5 77 991 �--3 - 8 127.01 a35o f R JSrf* SLJBSURFACE t AS-BLALT ► w �(„ LC�X{Ui Lf-DT 51 r'J:.__.[:1-'i LATE 7-26- 4 SCI-LE 1* PREPARED BY-.. FLYNN j4ssx-p. c. '1 PO 00 BOX ,5 e 1 CERTIFY THATTHE SEPTIC SY5TE?.'. %AAS IN5iALLEG AS SHONdtdo PL4� l �la i' to THIS P[ANIS NOT INTENDMACS A WARRANTY OF THESIS7Eki, 1 { FOUNDATIONCERTIFICATION AND LOCATION By PW-KAli;?PiSKt 440t. iSUC< /