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HomeMy WebLinkAboutMiscellaneous - 73 FOREST STREET 4/30/2018{ �,r } � � ��`4��1 � � `� ,� „ _ <. � i n 5�' a V W T 0 Z7 m m m FOR M 'jf/!J/v/ OF- PHONE- F PHONE �,� � 8�9 Y AREA CUDE NUMBER EXTENSION MESSAGE TIM E CALL LEASE CALL WILL CALL AGAIN CAMETO SEE YOU WANTS TO SIGNED LIJniyersal 46003 t / 17 SLOPE 26QU11e6: PE/ V T (/50) X = /50 - = ....... DE5I6N ELE!/QRON .4T ......... (TOP OF STONE) _ ................. I ........... EXI5TIM ELEWRON 4T......... REQU&,eED FILL = ELEl/.dT/OA15 DE5/iN A5 !3U/LT INI! P/PE OUT Of HOUSE ! . .o I/VI! PIPE INTO T4NK a I/VI! P/PE OUT OF T4NK INV. PIPE INTO D. BOX / INV P/PE OUT OF D450 y I r I ` - INV END OF PIPE 1. - I Wd Tif-le EL EV,4 TION .4VE2,46EE STONE DEPTI-I ,4T PROBE NOTE.- 7-1//5 PLAN /5 NOT ,4 W.4,e,P,4NTY OF THE 5Y57 -EM 007-,4 //EelF/CQT/ON OF T11E LOCATION OF 7WE EYI.5T/N6 .57eUCTU2E5. LOT ( 8 FO-,gEST �51- G,�3 5 KE- SYSTEM /N j: FOR 5"L E : DATE: CWte/57/,4NS46 1/ &NCl/i/EM/N6.p INC' //4 XENOZ,4 AVE., ,y,4V4EeAl/L L, M.4. .o a 1. - LOT ( 8 FO-,gEST �51- G,�3 5 KE- SYSTEM /N j: FOR 5"L E : DATE: CWte/57/,4NS46 1/ &NCl/i/EM/N6.p INC' //4 XENOZ,4 AVE., ,y,4V4EeAl/L L, M.4. TOWN OF.,NOR'1*11 AND(.)VLR 0((ice arC(.)MMUNITV I)EVELOPMI-,t'JT,%NDSt-RVI(.'rS I LCALTH DEPARTMENT 400 OSGOOWSTREET NORTH ANDOVER, MASSACULTSET1 S 01845 Phone tiusnn 1'. SHwyfv' 978.088.9,542 –FAX Public Healib Director I ivil 11 i4spjkf,L"! �fto %vw%v. owno.1horthano ver.k(tip - Wcb0f! Al_P'PLj�.AlLQMa)R Me( WOIt.1,S (:'()N �.TR!L _ Cj.TIO!�LPU&NIVU. IMCATION: m �Y'&z ot,; LICENSE 11) INSTALLER NAN1k':_.\)rh_1 7 PURASE PRINT SIGNATURE: TL"LLPHONI., \1 CHECK ()NtF/' ($250) COMPONENTREPAIR (indiCite what r:�1 tvf f�+J2 �k> (SiZS? NIM CONSTRUCTION: * If NEW C"ONSTRUCTION, plea"w attach the Foundition As-ollift Plan. $2SO.oO or SI.25 Fee, Aiwlicd":' yt(q), Voll"ClatJoll A,-.;. Built? o Floor Plans" No—, Approval oflicalth Agent r).,j(v. MAI? 1) ;, :! t I ('I!. I "I - 1'i 4 9'186P8 P. iib I abed il;l"p� I 6I:60 SOOZ'Vo M COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 'ECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 73 faRE,sr s?- I �tJb�Tfl A,r,Dovt�,L° Owner's Name: WO6Z740M�"� Owner's Address: LRE 05 Date of Inspection: 2 . .0S- DOVER VSNT Name of Inspector: (please print) 9/4/A4AI fi�aamT2 Company Name: A/O,zn-,4--rf::�t7- 1S-,&//Ro v.4favTf{G Mailing Address: fs w6 Ty/0 5� b,4/✓vr-.Qs5 1,,,4 O/ ps 3 Telephone Number: 27R- 7 ( 6 -.Z -510J eco CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3 IA"16 " 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. Notes and Comments NFGv /REPA)k?5 , tat6 N 40AIlF S j 9/1-A w/c L ;?fr-S5• ****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. Title 5 Inspection Form 6/15/2000 page 1 Pdge 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURF 'CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73aQ9'sr Owner: J'/Z /� X 4 Date of Inspec 'on: /-- z /;z k & S Inspection SummmWry: 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: lee—paired or more system components as described in the "Conditional Pass" section need to be replaced or lepaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. < Sbf PIPE. IzErILAc E,y£.ti7'I GvTe--LT £Shrrl"L� Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. AIA 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 leakin! and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 distribution box is leveled or replaced ND explain: IA 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 obstruction is removed ND explain: a • ' Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address W F02laS T S ,tX>rLTi� �i'Jot�' Owner: wde-5 �rY►F Date of Inspection: 7— C. C. Further Evaluation is Required by the Board of Health: 410 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 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 and volatile organic compounds indicates that the well is free from pollution from that facility 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: Page 4 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 F0,4 -Sr 57- t�it.�7y Owner: MF-R— Date of Inspection: Z-117- g o 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 '/z day flow ;-*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. I 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 coliform bacteria and volatile organic compomsds indicates that the well is free from pollution from that facility 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.] .AAYs/N0) he system fails. I have determined that one or more of the above failure criteria exist as cribed 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 sys em the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page 5 of 11 h OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 73 /ill Fs T S T /I*2IiY 1141UL IVC i2 Owner: IVOGS rR eyt4jC e Date of Inspection: — A4�oS 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 F t vA11-7-5 d/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: Yes no : Existing information. For example, a plan at the Board of Health. _A-*�_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 'Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: W ,co e EST S% ifJO�L T7� �},[/DDvI!�2 Owner: W 0 r,M a-42- Date -,2Date of Inspection: 7 % f /6 s - FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: l 10 gpd x # of bedrooms): Number of current residents:_ Does residence have a garbage grinder (yes or no): Al Is laundry on a separate sewage system (yes or no):W [if yes separate inspection required] Laundry system inspected (yeso� no):f� Seasonal use: (yes or no): �. Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): A/ Last date of occupancy: Cysf.4,,rA.T COMMERCIAL/INDUSTRIAL 111K Type of establishment: Design flow (based on 310 CMR 15.203): _ gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: TS Was system pumped as part of the inspection (yes or no): If yes, volume pumped: /rvp gallons -- How was quantity pumped determined? Ui4 6r Reason for pumping: //v!`E.2yi} t C_ r�7t�iC% TYP.C,OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or,no)- 6 Page 7 of 11 e OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -73 /raiz 4XT S7 - Owner: We' CS 2e""tt- Date of Inspection: Z L e BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron '140 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): /:54 -/Xe e0 AIV / 170N SEPTIC TANK: _ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) I I Dimensions: 6 X // X Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: c5 /3 S,V_�.2 V C4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): F/ X oc, r z- t 7 �3A- FL•�. GREASE TRAP: _(locate on site plan) 4/ /4 Depth below grade: 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: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 T �% 02 i4 �t7�cwCiz Owner:STr�MFa/L- Date of Inspection: Z 2-1< D r TIGHT or HOLDING TANK: V (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: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Zif 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.): 6006 (fGAv,p r� lONS PUMP CHAMBER: locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): A Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 F6QC- 5;-S7— Owner: TS%Owner• t4V6-T4c,",/ " Date of Inspection: ? D SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: --/— leaching fields, number, dimensions: 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.): CESSPOOLS: (cesspool must be pumped as part of inspect ion)(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 or no.): 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.): 0 i r ' Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 7-- S O( Owner: WO / STR 4/t4 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. TV4 10 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `73 Loet ST S Owner: kJ0 /Z ©I Date of Inspection: SITE EXAM( Slope b Surface water 7 ya d Check cellar c� vn-► P Perp Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Town of North Andover Community Development and Services Division Office of the Health Department 400 OSGOOD STREET North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/RS Public Health Director Date: 6? • 62 q)(,) U �� Address: -13 �� (e `7 `�� , North Andover, MA 01845 Re: Application for: Wa tooi4o na r Dear: SPo �L �0 C'(J1/14f uc�v)-1 00 Your application for I � 1 /�� Department. The application was denied on, 1. Missing information 2. Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the problem(s): (978) 688-9540 - Phone (978) 688-9542 — Fax has been reviewed by the Health 2004 for the following reasons: If #1 is checked, please supply: a. Floor plan of existing and proposed addition — all rooms b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocate the project If #4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult anengineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, 7 �I Reviewer Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-954 PLANNING 688-9535 f f�' Town of -North Andover MA° Watershed Septic System Servicing Report Date: -7- 9 Homeowner Street : Phone Nature of Service: Observations: Description of Work: Routine Emergency Pumper Address: -17- Phone : 63 Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids _ Heavy Grease _ Roots Other (Explain) Comments: MORTGAGE INSPECTION PLAN DECK _ lr � ,$CftL`EN o O c _ _ I �� — SILK ►JArK. �To�' 1~ Rer�. S.Cf�IL I I I i I. THIS PLAN IS BASED ON A TAPE SURVEY AND IS TO BE USED FOR MORTAGE PURPOSES ONLY. THIS IS NOT PREPARED FROM THE RESULTS OF AN INSTRUMENT SURVEY AND THE OFFSETS AS SHOWN SHOULD NOT BE USED IN THE ESTABLISHMENT OF PROPERTY LINES. eG4: C, x COUNTY DEED REFERENCE: PLAN REFERENCE: P,-r.o 981% BK.ZZ21 PG. 317 PL.BK. PL. I hereby certify that the existing building is located approximately as shown and was not in violation of the zoning bylaws at the time of construction. This building is not located in a flood hazard area. FLOOD HAZARD COMMUNITY NO. ,?500 ci BOUNDARY MAP NO.001 CF EFFECTIVE 15 EGIS�EAED LAND SURVEYOR DATE: ,2 - Z_ % McDONNELL H No. 33601 .. PLAN OF LAND IN NDR,TH ANIDaVrfZ, PREPARED 5ro I j 0 PZ- P,xrNr ,-AN,FS ;- _vim+-` C>a.MPBir L - ALE: I IN.= 4 G FEET BAILLIE & COMPANY CIVIL ENGINEERS & LAND SURVEYORS 89 VINE STREET READING, MA 01867 (617) 944-2767 r FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** /APPLICANT: �f}G,�l2t/yG�� L,,9 R,5 6Y Phone 6e -OS -01 Y LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street 9,3?e c't St. Number '73_ ************************Official Use Only************************ RECOMIRENDATIONS OF TOWN AGENTS: j Conservation ✓/ Administrator . Comments rOOa_ )A4JJ /fft; &Q- Date Date Approved 14 2 Rejected Date Approved Town Planner Date Rejected Comments Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date ApprovedL Date Rejected Date Board of Haalth - North And_nver,Hass- C1VED DATE DI SUPRNI _ l� a -eons! FASL OK �z SEPTIC STSTEH INSTALLATICK CHBCK LIST DAT pw� 1. Distance To: i� LOT `i� -�� sT �RtiLS.. 'EXCAVATION OK PAIL lI-Lz a. Wetlands b. Drains c .. Well 2. Water Line Location 3. No PPC Pipe 4. Septic Tank a. ..Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flo Ang Equal Amounts c. No Back Flow 6.- Leach Field or Trench a. Dimensions b. Stone Depth c. Capped lids 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 I .. n .0 GGt.-C ;' U- 7(7, L H s->izo", 0-[ T�1rd �LI:IT;;aH 'G pJVo�,7 pzeo�[ `)uTUUUT�T :of quas saidol) S861 `LT 'uPf uo aungTa.1, aT2u3 aaua.zMv7 ur 00110 t.nz uour.z T vq D puQpATp6 't' : �g •-4umqu-foddp Xq pup •ur•d 00:Z o-4 uoou 00: ZT 1110.z9. AEpsans uo ' dy1 '.XanopuNLIMON gDDagS uTUN ON `QuTpTTnQ uMol `aoT330 uo-tss-rL uio0 uoT:jpn.zasuOD OLl-I qp aTgPjTpnp a.zp supTJ; suralsAs Tgdas pup. sApMaATzp IsasnoLl Ippod p VuTq5najsuo5 3o sasodand .zoo — ppog puoa qpa.z0 00t Is pupT aagTp o l spT-[R eloaTag � u TTapY1 3o quaquI 3o 1 90TION a4l u0 J V . ' ' 1DAO U � � P � LI�zoN laa.zls uipyl 0ZT 'Woo'd QuTIaal.J, QuipTTng uMos atll 1p •Ij'd 00:8 qp 9861 £Z Azpnupr uo QuTaR9H oTTgn*p I-ToLI TTTM uoTssTunuoO. uoT-jpAaasuo0 zanopuH Lj-gaON 0141 go uoTjpnuTjuoo aL q 'MEZ Aq uoTIoaload pupTgom s zanopuNr LPzoN 90 uMoZ atP ptip 'papuaure st? '0'7 uoTIoaS •TCT aaldpLlo sMVI TvaauDD sigasnLlopsse,, 6IOV uoTIoa101d sput;TIaM OLD 90 AlTaOLl-Irlu aqq o-4 juensand SOIL -C99 3NOHd3l3l • NOISSIWWOJ NOIIVASgSN00 d0 30IddO • M s.11, :,nH:)VSSV W '2f3AOCINV HIHON JO NMOL BOARD OF HEALTH No.Andover, Mass. APPROVED - DATE &-1 ProvidCds 6 SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT j !��C DISAPPROVED DATE ✓ Reasonss �l Title V FAIL Oa Reg 2.5 The submitted plan must show as a minim,: a) the lot to be served-area,dimensionsof #..abutters b location and log deep observation 9L.9 -distance to ties c location and results percolation test, -distance to ties d design calculations & calculations sh tiring required leaching area (e) location and dimensions of system-"nc:..uding reserve area f) existing and proposed contours (g) location any wet areas within 100' of a, -wage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer - (i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files (j) known sources of water supply within 2001 of sewage disposal o _ system or disclaimer (k) location of any, proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of.basen.mt, plumbs pipe, septic tank, distribution box inlets and outlets, listribution field piping and Other elevations (r) maximum ground water elevation in are,: sewage disposal system (s) plan mast be prepared by a Profession I Engineer or other professional authorized by law to pre►,are such plans Reg 6 Septic Tanks (a) capacities -150% of flow, water ta} .es tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wal.1 or inground suimm :ng pool (d) 251 from subsurface drains ---Reg-10.2 7 Distribution Boxes 1(a) s pe greater 0.08 Reg 10.4b) Atmp