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Miscellaneous - 720 FOSTER STREET 4/30/2018 (2)
i Commonwealth of Massachusetts City/Town of RECEIVED System Pumping. Record JIJi_ 2 8 205 Form 4 '• • TOWN OF NORTH ANDOVER DEP has provided this form for use,- by local Boards of Health. Other forms maY&TQ;, but the information must be substantially the same as that provided here. Before using -this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / ' h •side of ho e, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Un er ec c Address!- Cdy/rown ( l� State Zip Code 2. System Owner. Name Address (d different from location) City/Town ' State Zip Code 3� Telephone Number B. Pumping 1. Date of Pumping 3. Type of system,- 0 ystem: ❑ Other (describe): Date 2. Quantity Pumped: Canons r Cesspool(s) ' ptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes If yes, was It cleaned? ❑ Yes ❑ No: " 5. Condition ofstem- 4<�5 6.- System Pumped By: Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Lo do where contents -were disposed: C .L S Lowell Waste Water 0 Date t5form4.doc• 06/03 System Pumping Record •Page 1 of 1 t5fomA.doc• 06/03 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record FJUN 3 0 2014 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for usezby local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using Ahis form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, Left/ ' side of hou , Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck City/Town 2. System Owner. Name Address (d different from location) citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ �— Sat— State Zip Code 9C\\ V`�vk-1101,,,�, ae-i sta^Q � � j i Zip Code Telephone Number t Date 2. Quantity Pumped: Gallons t—? Cesspool(s) eptic Tank❑Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of 6. System Pumped By: If yes, was it cleaned? ❑ Yes ❑ No; Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio where contents were disposed: Lowell Waste Water .so Gc:�% ��N System Pumping Record • Page 1 of t Commonwealth of Massachusetts _ a City/Town of r��EIVE® System Pumping Record N Form 4 M DEP has provided this form for use -by local Boards of Health. tn��>�(,V�Af "� , ut the information must be substantially the same as that provided here. rng th15 fo heck with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, Left /' t side of hour , Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address QCD City/Town f6 State Zip Code 2. System Owner: Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code Telephone Number r--1 Lf`( t' 2.u n Q a tity Pumped Septic Tank Date Cesspool(s) C� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [lNo If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of System: Air 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water *ule Date t5form4.doc• 06/03 System Pumping Recons •Page 1 of 1 Commonwealth of Massachusetts IM City/Town of R�Iv�® System Pumping Record JUN U b 2012 5 Form 4 M v TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other for rris-naay- ie sei � j information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / ' _ ide of house Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under dec c Address City/Town State Zip Code 2. System Owner. Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code Telephone Number a-a'—� "�'- Date 2. Quantity Pumped Cesspool(s) eptic Tank l�- Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of� 'j A o� � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio ere contents were disposed: G.L SS.. 1. _ Lowell Waste Water WINMww • w� Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 4807 Ot NORT-,�% . O Town of North Andover `;'•r HEALTH DEPARTMENT ,S.,ACNUStA CHECK #: S-S,!?V DATE: LOCATION: J� ' H/0 NAME: CONTRACTOR NAM : 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) $ ❑ Title 5 Inspector $ itle 5 Report $i ©• ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Asses: 720 Foster Street JUN 017 2010 Property Address ITOWN OF NORTH ANpOVER I Gerry Shimmoeller HEALTH DPAAM AIM-kiv Owner Owner's Name information is required for North Andover every page. City/Town Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. V%-41 ISI MA 01845 State Zip Code 6/9/2010 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 J. 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 SI15 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority 6/9/2010 In p or Signatu 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 •(X9/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 720 Foster Street Property Address Gerry Shimmoeller Owner's Name North Andover MA 01845 6/9/2010 Cityrrown B. Certification (cont.) State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 720 Foster Street Property Address Gerry Shimmoeller Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 State Zip Code 6/9/2010 Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover MA 01845 6/9/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ ' The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover MA 01845 6/9/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes - No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or, tributary to a surface water supply. ❑ n 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 — IVVPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover MA 01845 6/9/2010 every page. Cityrrown 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):,- N/A Number of bedrooms (actual): , 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 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 720 Foster Street Property Address Gerry Shimmoeller Owner's Name North Andover Citylrown D. System Information Description: Number of current residents: Does residence have a garbage grinder? MA 01845 State Zip Code 6/9/2010 Date of Inspection Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ,•7 Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No On well water ® Yes ❑ No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09/08 Title 5 Oficial Inspection forth: 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 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover MA 01845 6/9/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of 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 1000 gallons Measured tank Inspect tank 8t baffles. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 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 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover every page. Cityrrown D. System Information (cont.) MA 01845 State Zip Code 6/9/2010 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Tank original d -box & field installed 10/18/1989, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 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 0.5 feet ❑ Yes ® No ❑ 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: 7'x5'x4' Sludge depth: N ❑ Yes ❑ No t5ins - 09/08 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 720 Foster Street Pumped septic tank, heavy solids. Inlet baffle ok. Outlet baffle ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • 09108 feet ❑ polyethylene ❑ other (explain): Date Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover MA 01845 6/9/2010 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 24" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 3" 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.): Pumped septic tank, heavy solids. Inlet baffle ok. Outlet baffle ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • 09108 feet ❑ polyethylene ❑ other (explain): Date Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 =jdl_ Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 720 Foster Street Property Address Gerry Shimmoeller Owner's Name North Andover MA= 01845 6/9/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ „No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 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 M •�''r 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover MA 01845 6/9/2010 every page. Citylrown 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 & distibution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 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 mustbe pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 09/08 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �., 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover MA 01845 6/9/2010 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 40' ❑ 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 mustbe pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 09/08 ❑ Yes ❑ No 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 720 Foster Street Property Address Gerry Shimmoeller Owner's Name ,North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code 6/9/2010 Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 09108 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 720 Foster Street Property Address Gerry Shimmoeller Owner's Name North Andover MA 01845 6/9/2010 City/Town State Zip Code Date of Inspection Owner information is required for every page. 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 1 Qr; C) wCkkwe� > ico t 2 hµ' �OQLI A f3vo z 1a Ito fI r = lOtC-.4ll t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 720 Foster Street Property Address Gerry Shimmoeller Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to hi h round water MA 01845 state Zip Code >4 6/9/2010 Date of Inspection U 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 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: Essex County Soil Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 31, Charlton Soil, Water > 6' Deep Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Forth: 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 720 Foster Street Property Address Gerry Shimmoeller Owner Owner's Name information is required for North Andover every page. Cityrrown MA State 01845 Zip Code 6/9/2010 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 - pg/pg Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Jerry bcnimmeoiler bUJ-JdJ-UU0U NEW ENGLAND RADON, 1J D. 603-893-4260 Fax: 603-843-8163 a ="," °� 11 A ll�dustnal Wa Y Elnail: despinal@newenglalidradon.com -- "" 'i;;Salem. Salem. New Hampshire 03079 Website: www,newenglandradon.com = ER WATER ANALYSIS RESULTS DATE: 21 Mar 2010 GERALD SCHI VD,0E'Li.RR 720 FOSTER STREET NO ANDOVER, MA 01..845 LAii6: 62897 Date 6 time Sampled: 03/18/2010, 1345 Date Received: 03/18/2010 TEST SITE: ----720 FOSTER STREET, NO ANDOVER, MA (538970) PARAMETERS RESULTS xsQui'R-EMENTS ANALYTICP:L DATE OF TIME OF MCL/SMCL METHOD ANALYSIS ANALYSIS HARDNESS *4 1.5.0 75 mg/1 S1`�340C 03/20/2010 IRON * -CO A 0.3 m9/.1 EPA 200.8 03/.19/2010 1936 MANGANESE *N <0.05 0.05 mg/1 EPA 200.8 03/19/2010 1936 P11 to 7.4 6.5 - 8.9 EPA 150.1 03/18/2010 1452 CHLORIDE *f 33.0 250 mg11 L'PA 300.0 03/19/2010 0730 SODIUM *8 66.0 /rt6 250 mg/1 EPA 200.8 03/19/2010 2034 NITRATES **R <0.5 10 mg/1 EPA 300.0 03./19/2010 0730 COLIFORM —I. A AaSENCE/190 ml P/A COLISURE 03/18/2010 1500 F, -COLT *fl A A%3LNCE/100 ml P/A COLISURE 03/18/2010 1500 THIS SAMPLE MEETS EPA PRIMARY STANDARDS FOR THE PARAMETERS TLSTzD. These parameters exceed the MCL* or are out of range: A = Absent; P = Present — EPA Primary standards are standards that are related to health issues. (www.epa.gov/r.afe,,ater/ mcl.html0mcls) * EPA Secondary standards are aesthethic in quality and should not affect healthy individuals. (www.epa.gov/safewater/mcl.htmlimcls) Authorized by., Juba Espinal fm_- NER, LTD MCL: Maximum, Contain ant Level. SMCL: Secondary Maximum Contaminant Level. NOTE: These results relate only to the sample as submitted to: the Lab. i - NFiLAC accredited analysis. � 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 tq determine the form they use. The System Pumping Record must be submitted to the local Board of Health or-th6 approving authority. A. Facility Information 1. System Location: Left side of house, side of hous Left front of house, Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address CityfTown State Zip Code 2. System Owner. Name Address (if different from location) Cityfrown B. Pumping Record 1. Date of Pumping Date --q -1a 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): State Zip Code Telephone Number — 2. Quantity Pumped. eptic Tank I o©c� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ,D-1qo-'– If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S:b Lo ell Waste Water F Signature f H ler F5821 Vehicle License Number 64(9-10 20 1� C�E t5form4.doc• 06103 System Pumping Record •Page 1 of 1 Commonwealth of Massachusetts RK C ,E_lV City/Town of System Pumpin%Record AUG 2 7 2007 4 Form " �t TOWN OF NORTH ANDOVER " HEALTH DEPARTN AFUT Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. reern DEP has provided this form for use by local Boards of Health. Other orfs ma 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* Address Cityrrown 2. System Owner: Name (if different from location) State Zip Code &>k& � vvw�-'o R -,q a -C Cityrrown State zip c:oae Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date /� 2. Quantity Pumped: Gallons Cesspool(s)ptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Id'No 5. Conditions o_ f System, If yes, was it cleaned? ❑ Yes ❑ No s,) U AS v 6. Syst m Pumped B�: Name Vehicle License Number Company VA contents►were d t5form4.doc- 06103 System Pumping Record • Page 1 of 1 9 NORT/y TOWN OF NORTH ANDOVER °'• 6�"0 OL HEALTH DEPARTMENT A 27 CHARLES STREET ' 1 NORTH ANDOVER, MASSACHUSETTS 01845 �9 saCH„SES� Sandra Starr, R.S., C.H.O. (978) 688-9540 - Telephone Public Health Director (978) 688-9542 - Fax Ta From: Fax: Pages: Phone: Date: Re: ` ❑ Urgent ❑ For Review i1 Please Comment ❑ Please Reply ❑ Please Recycle Please call 978-688-9540 for assistance with any questions. Thank you. xc: Address File Chrono File HP Fax K1220xi Last Transaction Log for NORTH ANDOVER 9786889542 Aug 07 2003 1:32pm Date Time Twe Identification Duration Pees Result Aug 7 1:31pm Fax Sent 816033569690 1:24 3 OK o� W O 6) n W N 2 2 W W UO O 2 In W n V V 0 W n n N W 0 _V W 2 O V 2 O W to 4 O �t m O m n W W W m W N W to N •ct Q) UO W O N W M W W W W [{ M t0 W G N m N V UC) N to e} to 0 v m n n O) W N N to l(7 N <} W n N O) W N N N M W n N N O W M O m Un W N W O) p7 p) W N pWp O O N a V' r 0 aD r (h (7 (h N N M O O C7 00 +- N N r (7 n r (7 d' O (h n W Un (O Un N V' (n n m d' (n (n No Un N N 6 Un N N to � (n Un O Un N m o w to N o N to N w M M f� n n f� n h n W W W W a n n n n W rn n n n n n W n n n n n n n n n co m m � v v �t N N N N N O) N N W W N N O Un � 7 V �' (O CO V V 'C V c0 'cY V 7 V' V 7 V V W 1 O) d' V (O (O (O n (O dD � Up � ('� W 00 M M W W �Mn connr-nrW.^_aNNrnrlo Wn^Nn°n°nr-��NNrCD W Nmcommaor r r- 00 r- W m^00 222 a(v rn m m rn m m rn rn rn rn rn rn rn rn rn m rn rn m rn rn(m rn rn rn rn n n n n n rn rn rn rn rn rn rn N rn v v C a L v W Nn�(owmwaaaaocamaomao(om(nmmrn0 N na T NO O O OOO O O O O O O O O O O O O O O O O O O O 4 0 0 0 0 0 0 0-. - 0 0Ommm000mmowamoommmmmmm00mm vvvvvvvvvmm 0 00 a 0 0 0 0 0 O O O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Ci¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢ �m222S-2222 2m2mm222mm-2m 22.5 .5.52222m E m m (Ea aEa (Ea m C C C C C t L L L L L L Z CD a) m> ---------- CD m .m m ro `mmm o 0 0 0 o E E E E E E E p g 0 0 0 0 8>00>8110>8000001, > 0 0 0 0 0 0 0> 0 0 0 a 0D)m O>>> O> E C C C C C C C C C C C C C C c C c C c c c c c C C c t t C C t N y y y y y y M N N N (¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢`¢`¢¢¢¢¢¢¢¢¢¢¢¢ 0 oU 4 a m O Q y (J a Cl) O o C W O m (D m n p S¢ v v m 3 m m Q U O m >'aV a Ninon¢¢ t¢ ¢ Nwv "u v oaa ¢¢¢ p in p` w p N 0— Q c o ¢ W rn m 2 ¢ Qac y mm m`m m� .oma .o me ��oom_o���CO cLi>'m MLO �xp �J o m o Ln o° °o m m m m U Cl) x Y > m v v v L m> m m m m D u)i Y t o o -0 o � N E a ip fn Q Q> c m S o m mm 1151 c� m m m S c Q > m � 0 0 0� o m a m m m« m a c o mm m CU a.(17NNrir r(OLO W ^mW 0V7O(°O(O �Ule cc o���a JJ�0ZO LLQOLLO ma(O c� v(DW�vtOa rWN('7 Cl) co(D vvW(n(mnN�aa°n)arU r0 t0 rW7mN t`+ "`;' () vh U U U C - \ m J E c (n to m m U i C,- 0 c o c m m C > N m m m C N N ` O -C w C C °' m N d .0 m C m m U ° m 'r - 2L La O E•Et v a'rn� m 0Na) c o ° i0�cC Ucco 0 m lD C C C c � 0) ° C >. 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LL's E —J C70 i ON Ec=j°W (Oos c`— (Qamiccm> Wca co 0 O m Ott m 3_> m0 m Qa _ Q; m LL m Y .O. m O" (7 LL LL 0d m C -C m > U 7 C (0 m m Z C m' O O J O� lL m V m 38 M, caro a0C ��ui c. _W m W m 0M— °1 - SaY��'�m c3+� csi O S .-a c _O YYa E i- (D w E f0 'fl m Z' m J c ?i m 0 C70 F ro- w cv)� �' 'O 6/ m R t m V W x Z J EO C M (0 2 LL h N E c CU `m mt mmmo ociw�°�'om(CL /0 ayi m mE m mm (7 O m m �o(ca.W oEcc-oEv>>d_33aDincoEo����� c Zs ¢ a V rr �0 ¢ it I-- a. rn¢xa�twm �Fm-�a a�UIwLL`¢�U) w C 0m¢ 0 �s k A. G. tiDWARDS 2617 Main Street North Conway, NH 03860 Tel: (603) 356-2776 Fax (603) 356-9690 40 Ffa�7A 603 356 9690 08/05 '03 10:10 N0.689 01 To: Pamela Frown Jerry Schimmoeller Fax: 978-688-9542 Pages: 5 including cover Dab: 8/512003 Re: Proposed Addition CC: ❑ Urpmt ❑ For Review ❑ Please Comment ❑ Meese Reply O Please Recycle e COnow to; Pamela: Thanks for your fax, the info was very helpful. Attached is a copy of the proposed addition, and the existing house for the 1" and 2n0 floor. Also attached are a site plan indicating set-off and a diagram of the existing septic system. The existing house has four bedrooms and 1 and % baths. Is my existing septic system adequate for another'/: bath? Regards, 0 Jerry .A. G—EDWARDS FROM :,GMS 603 356 9690 PHONE NO. 08/05 '03 10:11 N0.689 04 B'E'RT/F/ED FOUNDA TION' PLAN LOCAMD 11V A -Ila, DATE: Scott L..611es N. L. S. 50 Deer Mevdvw Road North Andover, Moss. ! CERT/fY TNAi OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BU/1- DING INSPEC TDR ONLY SHOWN COURL Y ANO SUCH USE 1S PM rH£ WlrH 7HEZA1IIN6l OETERM1NARON OF ZONING Sr LAWS OF CON/-ORMl r Y oR NON- Gwf7i "1rr IC-4AWHEN CONSTRUCTED. Jul. 29 2003 04:36PM P1 A. G-EDWARDS 603 356 9690 08/05 '03 10:11 N0.689 03 F .A. G..EDWARDS 603 356 9690 08/05 '03 10:10 No.689 02 I ■■■ on on Illa:• rra■ ■■■ c■ - ■■■ �. on ISSUE :.■.. ■ . ■ no ■■■■■ googol: NEWS ■ mof 0 ■ • 8■ d nommom 2::C=::::iMasONES �oi�in�••�e�. v©�0000�aeeHe� _ ■m ■ I ,1.. G. -EDWARDS 603 356 9690 08/05 '03 10:12 N0.689 05 FOSTER STREET 1000 &AI TAN 1C . (o" deep PLAN 5HOWING NEW 50SURFAC; SF WAGE 1>15POSAL 5Y5TEM 11. arc. LOCATION: "7zo FOSTER ST ARGILLA RD. No. - 4N.Do vrP, ANDOVER, MA 01010 OWNEK • MR. ;J ERR -Y -SHrMMo. LLER DATE ' aC7: 18� � 9 aq N� scale,. TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr, R.S., C.H.O. Public Health Director l TO: Fax: From: Pages: Phone: Date: Re: CC: (978) 688-9540 - Telephone (978) 688-9542 - Fax ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Please call 978-688-9540 for assistance with any questions. Thank you. xc: Address File Chrono File HP Fax K1220xi Last Transaction Date Time Type Aug 5 10:08am Fax Sent Identification 816033569690 Log for NORTH ANDOVER 9786889542 Aug 05 2003 10: 10am Duration Pages Result 2:18 4 OK V �. O". i yM Additions and Septic Systems Why do 1 need this approval? The Health Department must approve all applications for additions to houses served by a septic system before the Building Department will issue any permit. This is because there are several things that the Health Department must check, namely: • Does the addition meet setback requirements? • Is the septic system working now? • Where exactly is the septic system? • Will there be more flow to the system? • Does the system currently comply with. relevant regulations? • Is the system large enough to handle any extra flow? • Is there room enough on the lot for a new system and a reserve? All these questions address the problem of whether the septic system is or can be made large enough for the maximum number of people the house could hold. An addition of any kind when there is a septic system on the site is considered "new construction". What do 1 need?: You will need to submit floor plans for the proposed addition along with a complete floor plan of all floors of the house as it currently exists. The two plans should be in the same scale. You will also need a certified plot plan showing the outline of the existing house, the proposed addition, the location of the septic system, and any wells or pools on the site. These should all be to scale. It is also recommended that you have your septic system inspected by a certified Septic System Inspector. It is important that your inspector checks on the size of your septic system as well as how well it is working. Who do I see? See the Health Department if you cannot locate the septic system; there may be a plan on file. See the Zoning Officer to find out if your lot and the proposed addition meet # HD -03 Zoning requirements. Check with the Conservation Department to discover whether wetlands will be a factor in your project. Then submit your entire package to the Health Department for a decision on your septic system's fate. A Civil Engineer could help you with this process. How do 1 do this?: To start the process you must first go to the Building Department and apply for a permit for an addition. You will pay a fee and receive some paperwork. You will probably have to go through the Conservation Commission process if there are any wetlands anywhere near your project site. If your site is located in the Lake Cochiewick watershed, then you should check with the Planning Department to see if you need a special permit. If you have submitted your application to the Board of Health, staff can be reviewing it while you are going through other departmental processes. A final approval and permission for a building permit will depend on the approval of all pertinent departments. Other References: • 310 CMR 15.000 Title 5 (You can download a copy of Title 5 at www.state.ma.uWdep/brpZwwMZt5pubs.h tm) Town of North Andover Requirements for the Subsurface Disposal of Sewage List of properties in the Watershed (in the Community Development and Services office at 27 Charles Street) Town of North Andover Health Department - Community Development & Services Division This brochure is intended for education/ purposes only. 1t does not cover alllurisdictions or scenarios thatyour permit ,�oplication maybe subject to. Permit applications are site specific. v& ORTry I Deeks & Septic Svstems # H®- 0 1 SSACHUs�t Why do I need this approval? This approval is necessary for two reasons. 1) A Building Permit cannot be issued unless the Board of Health approves the application and; 2) The Health Department must make sure that the septic system will not be adversely affected and result in a threat to the environment or to the public health. When a deck is added to a house that is served by an individual septic system, the Health Department must review the application to make sure that the deck isn't located over the septic tank and the deck supports aren't on the tank or in the leach area. Any one of these conditions could jeopardize the proper functioning of the septic system and/or cause a system failure. What do I need? For the Health Department review you will need the following documents: • Scaled plot plan with house and septic system accurately located, • Plan location of your proposed deck at the correct scale added to the plot plan If you do not have this information in your own files, the Board of Health may be able to help you by providing a copy of your septic As -Built plan. Who do I see? To obtain a copy of your As -Built (the plan that shows your lot, house and septic system as it was buil4, you may request a copy to be made at the Health Department if one is on file. If you cannot obtain a scaled copy, you may want to request that your septic tank pumper come out and locate the septic system components. A Civil Engineer may also locate the system and can then prepare a certified plot plan. Once you have the plot plan and are ready to site the deck, there are a few rules you need to keep in mind. They are: • Decks cannot be placed over septic tanks. • Deck supports cannot be placed on a septic tank nor within 5 feet of the tank or line to the tank. • The deck must be at least 10 feet from the leaching area. How do I do this? To start the process you must first go to the Building Department and apply for a permit to build a deck. You will pay .a fee and receive some paperwork. If you are in the Lake Cochiewick Watershed you should check with the Planning Department about a Watershed Permit. You may also have to go through the Conservation Commission if you have wetlands on or near your property. At the same time you are talking with Planning and Conservation, you may submit your paperwork to the Health Department for review and approval. If there is a problem with the application, such as information being .missing, you will be contacted by a staff member of the Health Department. A final approval and the issuance of a building permit will depend on the approval of all pertinent departments. Other References: • 310 CMR 15.000 State Environmental Code Title 5 (Download a copy online at www.state.ma.us/clew-b�r-wwwwt5p ubs.htm) • Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage • List of properties in the. Watershed (on the counter) Town of North Andover Health Department - Community Development & Services Division This brochure is intended as education of the local permitting process only. It does not cover al1jurisdictions, or scenarios thatyour permit application maybe subject to. Permitapplicanons are site specific. pvsa *N , Pools & Septic Systems #.HD 02 Why do i need this approval? Unless the Board of Health approves the location of the proposed pool, the Building Department will not issue a building permit. The Board of Health reviews all applications for residential pools that are proposed for sites with septic systems to make sure that the pool is not being placed on top of the septic system components, on or in the leach area or on or in the reserve area. In addition there are certain setbacks to the septic system and any well on site that must be maintained. What do I need? For the Health Department review you will need the following documents: • Scaled plot plan with house and septic system accurately located, • Plan location of your proposed pool at the correct scale added to the plot plan If you do not have this information in your own files, the Board of Health may be able to help you by providing a copy of your septic As -Built plan. Who do I see? To obtain a copy of your As -Built (the plan that shows your lot, house and septic system as it was buil4, you may request a copy to be made at the Health Department if one is on file. if you cannot obtain a scaled copy, you may want to request that your septic tank pumper come out and locate the septic system components. A Civil Engineer may also locate the system and can then prepare a certified plot plan. Once you have the plot plan and are ready to site the pool, there are a few rules you need to keep in mind. They are: • In -ground pools must be at least 20 feet from the septic system leach area and at least 10 feet from the septic tank. Aboveground pools must be at least 10 feet from both the leach area and the septic tank. If there is a well on the property, regardless of the well's use, then: • Both types of pools must be at least 15 feet from the well. These setbacks include all parts of the pool, such as fences, decks, cement walkways and grading. How do i do this? To start the process you must first go to the Building Department and apply for a permit to install a pool. You will pay a fee and receive some paperwork. You will have to go through the Conservation Commission if you have wetlands on or near your property. It is always wise to check with the Conservation Department whenever you are planning an outside project that will result in excavation of soil or removal of trees. You can, at the same time you are working with, Conservation, submit your paperwork to the Health Department for review and approval. If there is a problem with the application or if information is missing, you will be contacted and asked to supply additional paperwork or clarify something on your application. A final approval and issuance of a building permit will depend on the approval of all pertinent departments. Other References: 310 CMR 15.000 of the State Environmental Code, Title 5 (Download a copy online at www.state.ma.us/dtWbrp/wwm/t 5pubs.htm) Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage • #CD- 01 Notice of intent (NOI) brochure • #PD -01 Watershed Permit brochure Town of North Andover Health Department - Community Development & Services Division This brochure is intended as education of the local permitting process only. It does not cover a//jurisdictions or scenarios that your permit application maybe subject to, Permit applications are site specific. � � f GOT 2 X05 1) L.or 13 per_ -0-25 -25 JF 1 POW �°.iomm o mm r 0 ® ■ A ■ O ■ a :�>, ,•t •� �.� Y � �" �� ; h, ,r.��,a Commonwealth we th of Massachusetts " I' Massachusetts System Pumping Record System Owner st'- " U4111w,-� aj alv— Date of Pumping: Cesspool: No f Yes [] System Pumped by: Fate" System Location Quantity Pumped: jallons Septic Tank: No [ ] License # Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: Yes [J--' _a/ L+iIIIIIHilllot Alaekdr illselli + � �ggSgC�IUlitll�li !!s'tltlltl"Vttilti 1 I'm vv0 • /� ' ,� � � , i;�+�dillll}' rules,+.alt l /�iad coselluull 10+., .� a �eS ►� Llret�s� at S��IeHt i ulH,�rJ CutNenls.ltro+sle►trJ I++s � � � �` n ' Date INslrlrl�t - . i i TOWN OF NORTH ANDOM NORTH ANDOVER BOARD OF HEALTH REPORT OF PERC TEST ADDRESS OF SYSTEMJOZ'a2 TOS I NAME OF PROFESSIONAL ENGINEER CR SANITARIAN CONDUCTING TESTS A, z ae, - /1, 7 NAME OF LOT OWNERA.), 4clp,)e �, , GyG . ADDRESS Soil Loe: DATE �,2, SHOW APPROXIMATE LOCATION OF PITS ON SKETCH ON REAR OF PIIS SHEET Total Topsoil Subsoil Depths & Tvoes Water Level Pit Denth Time to Time to Perc Tests Depth Saturation Time Drop 1211 - 911 Drop 911 - b" Other Considerations: Recommendations: Signature o 4 L G�u�C1Z JA LL v— O N i �i r I' tl G � fd O Q C � ty I f .t t � C O � y f O C. n 7 a Q c L � L G1 O O � 6G '0 C R7 _ 1 w O O E C Gl O ,O io � GCQ 2 O cv O m O i � %+ F- O f= Q O Q t w O Q O E m 3 U O G C a m TO: NORTH ANDOVER, MASS '!25�7/ /8 19 77 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at %� ' c 57'� � 7 - North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 e x f ng'u_"aeter/RegAanitarian +\Sj13S1? �a� N w 9fwkLJWL (QE:>> ) r� OFFICES Of : 3+°;�"T Town Of BUILDING 0NORTH ANDOVER �. CONSERVATION • x , i I IEALTI I UIVISON (A' 1ACNUl4 - PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN FI.P, NELSON, DIRECI.OR CONSERVATION COMMISSION PUBLIC HEARING PURSUANT TO THE AUTHORITY OF THE WETLANDS PROTECTION ACT, 1:2() NWi►) Sir("rl No►Il) A►uaover, NI;issm'hus(,U5 018111711 (508) 682-6483 MASSACHUSETTS GENERAL LAWS CHAPTER 131, SECTION 40, AS AMENDED, AND THE TOWN OF NORTH ANDOVER'S WETLAND PROTECTION BYLAW, THE NORTH ANDOVER CONSERVATION COMMISSION WILL HOLD A PUBLIC HEARING ON: Wednesday, August 16, 1989 AT 8:00 P.M., AT THE SENIOR CENTER,LOCATED AT THE REAR OF THE TOWN HALL, ON THE WETLAND DETERMINATION REQUEST OF: Dominic Giarusso LAND LOCATED AT: Lot B - Sal em 'rPet (Rear of #318 S!- (30413b OP No►�TH �tiPOVEI�, MA, T SS D15APPRU UED R�SoNS = W, SO PFVI 0 WELL 5EPrIc SY STS PE'Sl6AJ s =D /PR�oviN6 Aurhoi-�iry PCAt1 DES+ &A.)6D.4Ti C7�1.�(jU�JTt�IJ 1NSP�G1-10tiJ SrPtl 6 SYSTEM 1 J S -VO "TI OA J 94rc 0 045 E] Fi41L. ' Q5P6,;-'tlon) PI PE F -Rot -A t Ion 1-0 T/J 0 K Ll Pry S5 `Q F/O)L 4PP130vEp Uwc-, ADPIT1A1p�v , DiSAPP)ZovF,D R�Cjo tis D rC-" FIti,Q(. APPROVAL #720 /000 &,a �R TAN K 20' l," deep �q BOX. - 1- 40 BATESON ENTERPRISE%- INC• . 711 ARQILLA .RD. ANDOVER, -MA 01810 WELL DATA3ASc r ADDRESS: �i AG= OF 7N-? rr w=LL DR? �_E?:'� 'W—ELL FE PII CT ,T: �v ALL LOCA-17ON: X �- 1-c:;�--cam- V=• ---SELL Pylli DA.T: DEPT=T 0 r TYPE OF Writ: a_ D b. DUG =OFTA-7HRHE`a-RING CK. WA=AYALY=DAr_- - OTtifANGANE=- Y _. . =IRON: Y N 0 Y1/20 rV ADDRESS: AGE OF W i I.: W FALL DRILL`S PERKY= WELL LOCATION: WELL PERDEP i H OF WEI.I i YPE OF WE'LL: z. DRI'i.LED b. DU c. U�Ii��tOrrlN TYPE OF WATER BEARii TG ROCK: WATER ANA i PSIS DATE: Y N KIGH LRON: Y N 07r7 --,-R CONTA vMNA- TS: Y 'ttillfN ttt���l�it �r ti��99llt;�lU�@N+� tri�•r a ' U1f 1����V�M Rw CH / /YI f'j'I 0 CLL , �. Dole � cilli lily.. or No 11' Vol_ t'pefi xrt►i: y 1t�n i'irf�l�rl;ci liy t` �d� t t`� Llma# 0 y F •.�1.:Y :': 4 'L • , r 4 �� r ' %�► 12 l i # Ty :i � .4 Y DATE:5��— TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD & ADDRESS SYSTEM LOCATION (example: left front of house) (�3AV, Sac�e DATE OF PUMPING: 5--q��QUANTITY PUMPED � � GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) �U�°iti U t�-'J,H �. S ;.,AY 1 4 2001 CONTENTS TRANSFERRED TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: I- 17 — SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) �� � e- a �aC) "Olisle- DATE OF PUMPING:?� QUANTITY PUMPED (CCGALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE �- EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: 6.1 �--- Commonwealth of Massachusetts City/Town of System Pumping Record _sa Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. vV RECEIVED NOV 2 5 2008 DEP has provided this form for use by local Boards of H26�wri3 sed, but the information must be substantially the same as that provi Is 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 front, left rear, left side of house. Right front, right r , right s de ofde of Address � j' J1' City/Town State � 2. System Owner: ( UA (A_&O MQ-,(_ Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping Zip Code State�0�p+�e Telephone Number Quantity Pumped Date 3. Type of system: Ej Cesspool(s) Ic Tank 0 Other (describe): Gallons Tight Tank 4. Effluent Tee Filter present? E] Yes [2-lTo— If yes, was it cleaned? Yes [j No 5. Condition of�Sy`s�te 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: I. L. S. Lowell Waste Water of F 5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 'C'\ Commonwealth of Massachu City/Town of System Pumping Record y Form .4 N "+ 4 1UI1 TOWN OF NARTFI ANDOVER DEP has provided this form for use by local Boards of UeMt f ffly de 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 front of house, right front of house, left side of hous , r hi t sib o�, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: a � Name Address (if different from location) Cit /Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: canons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes D- If yes, was it cleaned? ❑ Yes ❑ No 5. Condition 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: . L.S. of F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1