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Home My WebLink AboutMiscellaneous - 704 FOREST STREET 4/30/2018PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 10/18/2012 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box Repair By:Todd Bateson At: 704 Forest Street Map 105 D Lot 33 North Andover, MA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Susan Sawyer Public Health Agent JFIL7ECOPY 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com photo.JPQ (JPEG Image, 3264.x 2448 pixels) - Scaled (23%) http://web.mail.comcast.net/service/home/—/photo.JPG?auth=co&loc=... t.q /o - /a — i'�_ F Lol OCT X2012 TOWN OF NORTH ANDOVER HEALTH DEPARTUrwr 1 of 1 -0 10/18/2012 8:08 PM Commonwealth of Massachusetts Map -Block -Lot 105.D0033 BOARD OF HEALTHPermit No ------------- North Andover -BHP -2012- 0732 ------------------ ---- PA. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson ---------------------------------------------------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. at No 704 FOREST STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2012-073 Dated October 09, 2012 ----------------------------------------- - ---------------------------------------------- --------- Issued On: Oct -09-2012 BOARD OF HEALTH Commonwealth of Massachusetts BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct) byTodd Bateson ---------------------------------------------------------------------------------------------------------------------------------- Installer Map -Block -Lot 105.D0033 ------------------- at No 704 FOREST STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2012-073 Dated October -0-9,2-0-1- 2 ----------------------------------------------------------------- Printed On: Oct -09-2012 BOARD OF HEALTH M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tion r -Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal epair or replace an existing system component — Wt A. Facility Information nao Cityrr wn 2.- *TYPE OF SEPTIC SYSTEM*: Pump ravity (choose one) ***If pump system, attach copy of electrical permit to application*** conventional System (pipe and stone system) ❑ infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance A$ ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information TODAY'S GATE $ 250.00 — Full Repair $125.00 - Component RECEI EV OCT U 9 Zs`ii2 Name + Address (if different from above) /Q s1% & ® t S - L-/5_ Ckyfrown state _ Zip Code Telephone Number 3. Installer Infor-mation ''sem ies��✓ Name Name of Com ENTERPRISES, INC. 111 ARGILLA ROAD -- - 4. /'E-,LJI, M,+ Cityfrown state, Zip Code Telephone Number (Cell Phone # If possible please) Name of Company State Zip Code Telephone Number (Best#to Reach) Apprication for Disposal system Construction Permit - Page 1 of 2 SEPTIC SYSTEM. INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover.licensetl installer ,P F^thf-co1 tructioft fortheseptic system -,for -the propelt7 at: For plans by (Address of septic system) Relative to the.gppfication of Q3 And dated (in'staller'sname) Dated /a With r'evisiot I understand the following obligations for management of -this project: 1. A . s the installer, I am .obligated to obtain. an permits and Board of ealth approved plans prior to ,performing any work on a site. I must have the gpprovedplans and the permit on site when any work is b.&Z done. 2. As the inttaller,-I.must -call for any and allinspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules -an inspection and the system is not ready, then item three- shall• be. applicable.. completed prior to the applicable inspections as installer, 1 -10 1 d to. have the necessarywork 3 As the am . quire inspection rngledoft, of the items in, accordanci mdicatedbelow-4�Iiift'dei8tandtha recsi6stiagn ctibn, without cb pec ch unle§�:there is a� retaining wall, which bf.B Generali ,this this -is the. do' jn$t4c 1huspresent. shouiAbe� a6 st The r: t.roguost -the inspection but does. not have to be b. Final -Const iion Inspection firsi.do their inspection for elevations; ..des, etc. -dyer.g9m), from the engineer must As -built bi to: heal A 'at of vet. al OK (or e-mail thdeptQ ofhorthand be submitted- to.the Board of Health, after .*Lciinstaller.calls for.+an inspection time. InstiUermust be present for this. inspection, With a pump system,: all electrical -wotkmwt be ready and Able to cause pump to stork and. alarmto function.. w en All is complete. 'does not c. FinafGtade, — Installer must request inspection.' h.0 grading. plete. Installer have to be on-site. 4. As -the installer,'I . un:derstand that only I may perform the'work (other than -qmple excavation) and lam required-- to complete. the -instillation of the system identified in the, attached application 'for. installation.: J further I A INVrm -111U2Vfz1, �WLJLLILAALIL 111AL;0.1aF au 14vl0-1-2 5., Asth" stiler,:I understand thatl most on-site during the perf&nance of tie following construction steps: a. Deterniihadon that.theproper elevation of the excavation has been reached. A Inspection of the -sand and stone to be used. c. Final inspection' by Board ofHealth staffor consultant d Installation.. of tank, D -Boor, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that 1 am solely responsible for the installation .of the system as per the approved-�ans. No instructions -by thehbv4dowger, gentral.-gontrietor.-or my.other42ersons shall -absolve me!2f this obligation. ay' I s Date): Undersigned Licensed Septic.Inaaller !0d e DD1.44 TN=e,w- Mat) P "`"T"',. Application for Septic Disposal System TODAY'S DATE aConstruction Permit -TOWN OF OVER, MA 01845 $ 250.00 - Full Repair $125.00 - Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: ❑Residential 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, d not to place the system in operation until a Certificate of Compliance has been issue y is V of H alth. Name Date Approved: (Board of Health Representative) 12 j2— % Date the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached. Yes,/ % No 3. Pump S sy tem? If so, Attach copy of Electrical Permit Yes No 4. Foundation As -Built? (new construction ronly): Yes No (Same scale as apptoved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses! 704 Forest Street Property Address Joe Lehmann Owners Name North Andover City/Town MA 01845 State Zip Code RECEIVED NOV 2C 2012 3WN OF NORTH ANDOVER HEALTH DEPARTMENT 10/12/2012 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. A. General Information 1. Inspector: Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State S115 License Number 01810 Zip Code 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: it ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a4� 10/12/2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 704 Forest Street Property Address Joe Lehmann Owner's Name North Andover MA 01845 10/12/2012 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install riser on septic tank, outlet tee in septic tank & new d -box, septic system now passes Title 5 Inspection. 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 6259 f NORTIr , � s Town of North Andover HEALTH DEPARTMENT s�cNust CHECK #: DATE: LOCATION: 10-1 .e4` 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 Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ O Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Heal Agent Initials White - Applicant Yellow - Health Pink - Treasurer f 4 Of �o y1ti0 'T • Town of North Andover •ti' HEALTH DEPARTMENT �ds�cMus`� CHECK #: t0 DATE: LOCATION: -70-e`�i`a H/O NAME: 6'1 t.st' 1'jVY1Gt,h t�} CONTRACTOR NAME: �UY1 1io 5 . ;t Type of Permit or License: (Check box) ❑ Animal $ r j ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral. Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ „s ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ # s F ❑ Swimming Pool $ . y ❑ 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 $ 13 Title 5 Report $ 1, ❑ Other. (Indicate) $ HealAgent Initials' White - Applicant Yellow - Health Pink -Treasurer, ;r C f. .f... s Commonwealth of Massachusetts RECEEI ED 4 Title 5 Official Inspection Form 2 2012 Subsurface Sewage Disposal System Form Not for Voluntary Assessme is TOWN OF NOR f A (DOVER M 704 Forest Street HEALTH DEA ENT Property Address Joseph Lehmann Owner Owner's Name information is North Andover Ma 01845 9/20/2012 1 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 on the computer, use only the tab key to move your cursor - do not use the return key. ISI A. General Information 1. Inspector: Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown 978-475-4786 Telephone Number B. Certification State Zip Code S115 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Nee Further Evaluation by the Local Approving Authority 9/20/2012 In4ettod Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 _tel_ Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 704 Forest Street Property Address Joseph Lehmann Owners Name North Andover Citylrown B. Certification (cont.) Ma 01845 State Zip Code 9/20/2012 Date of Inspection 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 • 11110 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 704 Forest Street Property Address Joseph Lehmann Owner's Name North Andover Ma 01845 9/20/2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 704 Forest Street Property Address Joseph Lehmann Owner's Name North Andover Cityrrown B. Certification (cont.) Ma 01845 State Zip Code 9/20/2012 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed,at a DEP certified laboratory, for fecal coliform bacteria indicates absent andt rreesence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that -no other failDre criteria are triggered. A copy of the analysis must be attached -to -this -form: -- -- -- 3. Other: Outlet tee in septic tank & d -box needs to be re 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 El ® 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'/ day flow t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 704 Forest Street Property Address Joseph Lehmann Owner Owner's Name information is required for North Andover Ma 01845 9/20/2012 every page. Citylrown 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 704 Forest Street Property Address Joseph Lehmann Owner Owner's Name information is required for North Andover Ma 01845 every page. Cityrrown State Zip Code C. Checklist 9/20/2012 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): 600 t5ins -11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM , 704 Forest Street Owner information is required for every page. Property Address Joseph Lehmann Owner's Name North Andover City/ Town D. System Information Description: Number of current residents: 9/20/2012 State Zip Code Date of Inspection Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d No 9 ( Y 9 (gP ))� Detail: On well water, >100' to septic system 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 Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 704 Forest Street Property Address Joseph Lehmann Owner Owner's Name information is required for North Andover Ma every page. City/Town State D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: 01845 9/20/2012 Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2008, owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Yes ® No ❑ 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 -11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 704 Forest Street Property Address Joseph Lehmann Owner's Name North Andover City/Town D. System Information (cont.) Ma 01845 State Zip Code 9/20/2012 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 28 years old, 6/11/1984, 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 thru wall. 3" PVC in house. no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 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: 10'x5'x4' Sludge depth: Kili ❑ Yes ❑ No t5ins • 11/10 Title 5 Oficial 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 M , 704 Forest Street Owner information is required for every page. Property Address Joseph Lehmann Owner's Name North Andover Cityrrown D. System Information (cont.) Septic Tank (cont.) Ma 01845 9/20/2012 State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 3" 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 18" 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.): Outlet tee badly corroded, needs to be replaced. Depth of liquid at outlet invert. Tank 2' deep, needs to have riser installed on center cover 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 704 Forest Street Owner information is required for every page. Property Address Joseph Lehmann Owner's Name North Andover Cityrrown State 01845 Zip Code 9/20/2012 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: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11110 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 704 Forest Street Property Address Joseph Lehmann Owner's Name North Andover Ma 01845 9/20/2012 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 level & distribution equal. D -box badly corroded needs to be replaced. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 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 704 Forest Street Property Address Joseph Lehmann Owner's Name North Andover Cityrrown D. System Information (cont.) Ma 01845 State Zip Code 9/20/2012 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 25'x 39' leachfield ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 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 704 Forest Street Property Address Joseph Lehmann Owner's Name North Andover Ma 01845 9/20/2012 Cityrrown 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 -11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 704 Forest Street 9/20/2012 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 6 t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Property Address Joseph Lehmann Owner Owner's Name information is required for North Andover Ma 01845 every page. Citylrown State Zip Code 9/20/2012 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 6 t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 704 Forest Street Property Address Joseph Lehmann Owner's Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de th to hi In round water Ma State 01845 9/20/2012 4 Date of Inspection p g g 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: Date 83 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, 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 704 Forest Street Property Address Joseph Lehmann Owner Owner's Name information is required for North Andover Ma 01845 9/20/2012 every page. City/Town State Zip Code bate 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 PAr o Lo7- '65 OF 41 LIQ 40 OW 'rf4lS--r'Z.0f'1!?ry 1-1 LA;2CArEV /*5 Sk:)W*4 ONIPL M4 A4P C;::'mT'lJe!Z WITH *r+tm ,7x:;,WlQCA ZEQUL4TK;�W4 OF -TW-- Tcw4 oF 4wcck�, :CFt494-+4eZ c2r-�M;--r. -ri-y! A.qa='vjE rP4)aa.! 1 w A is Lc--P—lATEz;:, A fLoop 'GEOTECHW,':,COIVjM'tA OF.-MASSACHUS,,.,, 'o dw p, LOTS CL � AS -61-7- 4-z14 4c), D9 of i�v ver 2� S/ 4 IV i- N I 5 135-10 135-,3o //Y 13Z,45- 0-3ov 13 2, 13Z-64�. 132,o 3A f\p �vj V41 Ari 1-- 4, 000 1. 0111 if, Cil Joseph B. Lehmann 704 Forest Street North Andover, MA 01845 Phone: (978) 685-6362 DATE: June 6, 2005 TO: North ,Andover Health Dept. FSS Attention: Michele SUBJECT: Building permit application for 704 Forest Street Dear Michele: With this FAX z am, sending a copy of the septic system design for our home at 704 Forest Street. 1f you have any further questions, please call me at the phone number listed above. Sincerely, Joseph Lehmann dP 0 tjATT--W_ 14 as *t:� 44 ON71'-A4 AMD -lp"Pijes Wmi i -"m ftutu'A Vw-QJL4To=lL14 OF -M-;Uom PF slum Awcow", r44r � 4ap'.'s 7-P'V&L?'.jA 4 WOV UXATEz;p 0 A � -jolm `#t -Al - d CAD, GM09WAL CONSULTANTS OF 1AMACHUSEM jr4r, Lori Ile t .47 V Tll.,Ilr. p, z 1L Ile t Board of -Health - SUBSUEFACE DISPOSAL DESIGN CHECg LIST -LOT / DISAPFRWTD DATE 'PROM DAA Reasons: tle V 2.5- a Reg ( -- I- --- 10.2 _ 10.2 - l0.4 ' n.e submitted plan must shox as a MiMimnms ' ` the lot to be sewed -area, dimensions lot f,abutters I location and log &ep observation holes -distance to ties location and results percolation tests -distance to ties M enlstions shorti,*i.ng reouired leaching area design calculations k cali . location and dimensions of system -including nsservs area [1) existing and proposed contours� sal system or location any vot areas thin 100 of sewage dispo ' disclaimer -check wetlands mapping surface and subsurface drains vitnin 100' of sewage disposal system or disci - �i�, location an4r drainage easements within 100' of stege disposal . system or disclmer-Planning Board files a . kno= sources of meter supply vittdn 200' of serge disposal i system or discla..iner--- -jocation-of -aV proposed �-e11 io serve lot-10� ro_m 1hing facili`+ (i) location -of nater lines on property -101 from leaching facili a<) g�rbige bj:�g_sals no -SVG tca used in --construction bSo=o tem- edationsf basement., p1 - .P P?e s ' iiciV`ce (q) -P;$ stritlets,d-field piping a -inlets and�onui - - - meter elevation in area sezage disposal system; plan—mdst`f Ce prepared by a Professional $n€ineer or other_�- professional authorized by 1-aw to prepare such plans - # *3ks Se tic Ta _ ill c�acities-150%, of f'lo�;� nater table3 tees., depth of tees. access3 pumping } cl canou_t = - Pool c� 10' from_ cellar � l or ingrotmd P - - oj5+ from subsurface drams - - _bistributian Foxes - G} sope greatsr tion 0.08gump = - -- --_ = -- Subsurface Design Check List Page 2 ` Reg 11.2 11.4 11.10 11.11 leg 15.1 15.4 15.8- 3.7 teg 14.1) 14.3 14.-4-- 14.6 14.7 _ 114.10-f) FAIL 0K Leaching Pits Leaching pits are preferred where the installation is possible a) ,calculations of leaching area -minim m 500 sq ft b)' spacing a) surface drainage 2% d) cover material e) k'x2Ix4" splash pad f) tee at elbow g) no bends in pipe Brom d -box to pipe Leaching Fields a) no greater Tan 20 minutes/inch b) area-rainimrm 900 sq ft c) construction of field d) surface drainage 2 % e) 201 from cellar van or inground svimrAng pool Leaching Trenches - calculations of leaching area -min 500 sq ft b) spacing -4 ft mixt 6 ft with reserve between c) dimensions Id) construction e) stone surface drainage 2% DowzhTtffl.7. Slope a) slope y%x -�- into be shorn) be = -shown) _ / - C - t Board of Health, = SEPTIC SISTEM North An mer y,i 33. i' INSTALLATICd� CHECK LISP LOT'` pgID DATg AVATI Ob FAIL BI SAPPRNa easanst FM < OK ` 1. Distance Tot r , a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe %. Septic Tank a. -Tees _Length & To C1.ean Out Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box & Bo No Cracks a. Covera x - _• � b. All Lines Flowing Equal Amounts c. No Back Flow 6. . Leach Field or Trench a. Dimensions b. Stone Doth c; Capped Ihds d. Clean Double Washed Stone 7. Leach Pits a. Dimensions - b. Stone Depth c. Splash Pads d. .Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8, No Garbage Disposal 9. Anal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location -- b. Dimensions of System c. Location with Regard -to Perc Test d. Elevations e: Water Table O O U a) ra in RA M FT, - c o7 1 a � o � � o Q � w.. o E � m to s E O Q n a a c L � ti IWC Qt o tU E41 i R t 4? C ,a c a o E c � O ,0 io Q) OCQ 2 0 _0 0 m 1= � o a Q 4- 0 a � v 0 m U O C, U •y C O U 7 M fa Z MORTq 6264 0�41•0 �•,aA O � s Town of North Andover ' "AM HEALTH DEPARTMENT NU CHECK #:- DATE LOCATION: H/O NAME: CONTRACTOR NAME:-_� ��, Tvve of Permit or -License: (Check box) ❑ Animal $ ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type-,---- 0 ype:❑ Funeral Directors ❑ Massage Establishment $_ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp ❑ Sun tanning 4 ❑ Swimming Pool $ ❑ Tobacco ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ C� Septic - Design Approval $ fil] Septic Disposal Works Construction (DWC) P ❑ Septic Disposal Works Installers (DW() $ ❑ Title 5Inspector $ ❑ Title 5 Report ❑ Other: (Indicate) $ I - Appticant Yellow - Health Pink - Treasurer 9