HomeMy WebLinkAboutMiscellaneous - 75 WINDKIST FARM ROAD 4/30/2018N
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IN
A
Lot & Street It)J Map/Parcel
I
CONSTRUCTION APPROVAL
Has plan review fee been paid; QYE NO Permit#
Plan Approval: Date: Approved by: 7aAt
Designer: (?11e15 T1 A iV S & A) Plan Date: t24y� ti- to/��7
Conditions:
e Supply: Town Well
Well Permit: Driller-.-
Well
riller:Well Tests: Chemical �Date-roved
Bacteria I Date Approved
Bacteria II Date Approved
Plumbing Sign -Off:
Comments:
Wiring Sign -Off:
Form "U" Approval: Approval to Issue: NO
Date Issued By:
Conditions:_T��
Final Approval:
All Permits Paid?
NO
Well Construction Approval?
��
NO
Septic System Construction Approval?
NO
Certification?
YES
NO
Other
YES
NO
Any Variance Needed? YES NO
FINAL BOARD OF HE LTH APPROVAL:
DATE: // 17 q 7
APPROVED BY:
lo
N
lk N
SEPTIC SYSTEM INSTALLATION
A
Is the installer licensed? NO
Type of Construction: REPAIR
New Construction: Certified Plot Plan Review YES NO
Floor Plan Review < NO
Conditions of Approval from Form U YES NO
Issuance of DWC permit:
DWC Permit Paid?
DWC Permit
Begin Inspection:
Excavation Inspection:
Needed:
Passed:
Construction Inspection:
Needed:
As Built Plan Satisfactory:
YES:
NO
YES NO
Installer: �GG <5p&j
S NO
Approval of Backfill: Date:////Z/ By:�AA�
Final Grading Approval: Date: lBy:
Final Construction Approval: Date: /% By:
Certificate of Compliance: Approval: Date.,/(' 1l I
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information is
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page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
t5ins.doc • rev. 6/16
Commonwealth of Massachusetts
Title 5 Official Inspection Form RECEIVED
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments MAR -10 2017
75 Windkist Farm Road TowNoKt H ANDOVER
Property Address
HEALTH DEPARTME
Steve Flora
Owner's Name
North Andover MA
City/Town State
01845 2/11/2017
Zip Code ection
Inspection results must be submitted on this form. Inspection forms may n7bered in any
way. Please see completeness checklist at the end of the form. itj)/alte_e—\
A. General Information Q
1. Inspector:
Neil James Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
City/Town State
978-475-4786 SI -15
Telephone Number License Number
B. Certification
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
s
2/11/2017
Inspector's ignatu a 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 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.
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
75 Windkist Farm Road
Property Address
Steve Flora
Owner's Name
North Andover MA 01845 2/11/2017
CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from B.O.H., cut & remove trees & brush from leach area, locate & excavate buried
manhole, check ten feet of pipe in last manhole, pump septic tank, septic system now passes Title 5
insoection.
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.doc • rev. 6/16 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
75 Windkist Farm Road
Property Address
Steve Flora
Owner's Name
North Andover
MA
City/Town State
D. System Information (cont.)
01845
Zip Code
2/11/2017
Date of Inspection
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
0c�.e,
wa�)
Wou sc
r� '?>
:,I
L4
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t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
ip
Commonwealth of Massachusetts
City/Town of .
System P-rumping. Record
Form 4
DEP has Provided this form for use -by local Boards of Health. Other forms maybe *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. Facili.ty. Infonmiation
1. System Location: Left / Right front of house, Left / fight rear of Neuse Left / right side of house, Left /
Right side of building, Left / Right front of buildirig, Left / Right rear df building, Under deck
. Address � � ' ` „
City/Town l State Zip Coce
2. System Owner.
Name
Address (d different from location)
City/Town ' State Zi ��' P� Coo
s v
Telephone Number
i
r;
.6. Pumping record
1. Date of Pumping � 2. QuantityPumped: —�
Date p Gallons
3. Type -of system: ❑ Cesspool(s) [D -Septic k ❑ Tight Tank
❑ Other (describe): ' ,
4. Effluent Tee Filter present? F1 Yes [�� If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil. Bateson '
Name
Bateson Enterprises Ina
Company
7. Locajonwhera contents -were disposed:
Waste Water
F5821
Vehicle License Number
Date
t5form4.doe- 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts;`
Title 5 Official Inspection Form -
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Windkist Farm Road
Property Address N
Steven Flora
Owner Owner's Name
information is North Andover MA 01845 1/11/2017
required for every
page. Cityrr'own State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
.GO
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
A. General Information
Inspector:
Neil James Bateson
Name of Inspector
Bateson Enterprises Inc
Company Name
111 Argilla Road
Company Address
Andover
Cityrrown
978-475-4786
Telephone Number
B. Certification
MA
State
SI -15
License Number
01810
Zip Code
V
c N10 o11' Pio
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1/11/2017
lnipeooA SignatuW 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 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.doc • rev. 6/16 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
75 Windkist Farm Road
Property Address
Steven Flora
Owner's Name
North Andover MA 01845 1/11/2017
Cityrrown 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:
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.doc • rev. 6116 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
75 Windkist Farm Road
Property Address
Steven Flora
Owner's Name
North Andover MA 01845 1/11/2017
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑
❑
❑
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
❑ Y
❑ Y
❑ Y
® N
® N
® N
❑
❑
❑
ND (Explain below):
ND (Explain below):
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.doc • rev. 6116 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
75 Windkist Farm Road
Property Address
Steven Flora
Owner's Name
North Andover
City,rrown
B. Certification (cont.)
MA 01845
State Zip Code
1/11/2017
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 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:
Remove section of pipe coming out of last manhole with roots in it.
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.doc - rev. 6116
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
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is
required for every North Andover MA 01845 1/11/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes
No
❑
❑
the system is within 400 feet of a surface drinking water supply
❑
❑
the system is within 200 feet of a tributary to a surface drinking water supply
❑
❑
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Windkist Farm Road
a
Property Address
Steven Flora
Owner
Owner's Name
information is
required for every
North Andover MA 01845
page.
Cityrrown State Zip Code
C. Checklist
1/11/2017
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:
A
Number of bedrooms (design):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
A
440
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is
required for every North Andover MA 01845
page. Citylrown State Zip Code
D. System Information
Description:
Number of current residents:
1/11/2017
Date of Inspection
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
❑ Yes
®
No
Water meter readings, if available last 2 ears usage d
9 ( Y 9 (gp ))�
Yes
Detail:
Sump pump?
❑ Yes
®
No
Last date of occupancy:
Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes
❑
No
Industrial waste holding tank present?
❑ Yes
❑
No
Non -sanitary waste discharged to the Title 5 system?
❑ Yes
❑
No
Water meter readings, if available:
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Windkist Farm Road
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845
State Zip Code
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
1/11/2017
Date of Inspection
Pumped three years ago, 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Property Address
Steven Flora
Owner
Owner's Name
information is
North Andover
required for every
page.
City1rown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845
State Zip Code
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
1/11/2017
Date of Inspection
Pumped three years ago, 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.doc - rev. 6/16 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
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is
required for every North Andover MA 01845
page. Cityrrown State Zip Code
D. System Information (cont.)
1/11/2017
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
20 years old, 11/20/1997, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
El cast iron ® 40 PVC El other (explain):
S t t 1 II f Ii
❑ Yes ® No
5
feet
Distance rom peva a wa er supp y we or suc Ion Ine. feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC through wall, 3" PVC in house, no leaks.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
4
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'x 5'x 4'
Sludge depth:
3
❑ Yes ❑ No
t5ins.doc • rev. 6116 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
M 75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is North Andover
required for every
page. Cityrrown
D. System Information (cont.)
Septic Tank (cont.)
RAA
01845
Zip Code
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
3011
411
811
1111
1/11/2017
Date of Inspection
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of
leakage. Center cover has riser 18" deep.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
❑ fiberglass
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.doc • rev. 6/16
feet
❑ polyethylene ❑ other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
U
Title 5 Official Inspection Form
9
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is North Andover MA 01845 1/11/2017
required for every
page. City(rown 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
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
❑ polyethylene ❑ other (explain):
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.doc - rev. 6116 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
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is North Andover MA 01845
required for every
page. Cityfrown State Zip Code
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
1/11/2017
Date of Inspection
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. No evidence of leakage. Evidence of carryover.
Pump Chamber (locate on site plan):
Pumps in working order:
❑
Yes
❑
No*
Alarms in working order:
❑
Yes
❑
No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc - rev. 6/16
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is North Andover
required for every
page. City/Town
D. System Information (cont.)
Type:
MA 01845
State Zip Code
1/11/2017
Date of Inspection
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
®
leaching trenches
number, length: 2 trenches 46'long
❑
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.):
Soil ok. Vegetaion should be cleared over trenches, has a couple of small trees growing over & near
leach trenches. 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.doc • rev. 6116 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
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is North Andover MA 01845
required for every
page. Cityrrown State Zip Code
D. System Information (cont.)
t5ins.doc • rev. 6/16
1/11/2017
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.):
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
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is
required for every North Andover MA 01845 1/11/2017
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
t5ins.doc - rev. 6116
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
Duk
V
ltd
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
1/11/2017
Date of Inspection
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 4/26/1997
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:
As per test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
75 Windkist Farm Road
Property Address
Steven Flora
Owner
Owner's Name
information is
required for every
North Andover MA 01845
page.
Cityrrown State Zip Code
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
1/11/2017
Date of Inspection
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 4/26/1997
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:
As per test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Windkist Farm Road
Property Address
Steven Flora
Owner Owner's Name
information is North Andover MA 01845 1/11/2017
required for every
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information — Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Summary Record Card generated on 12/20/2016 12:19:44 PM by Tara Hurley rage i
• Town of North Andover
Tax Map # 210-109.0-0051-0000.0
Parcel Id 18855
75 WINDKIST FARM ROAD
FLORA, STEVEN K Since Jan 2014
LORRAINE I. FLORA
75 WINDKIST FARMS ROAD
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.62 Acres
FY 2017
UB Mailina Index
Name/Address Type Loan Number Active/lnact. From Until
FLORA, STEVE & LORI Payor
75 WINDKIST FARM ROAD
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 13776.0 - 75 WINDKIST FARM ROAD Last Billing Date 11/7/2016
1090453. 01 Cycle 01 Active
UB Services Maint.
Account No. 1090453
Service Code Rate Charge Multiplier/Users
MISCFEEADMIN FEE 1 1 9.18 1/
WTR WATER 01 ALL METER SIZE 464.50 /1
UB Meter Maintenance
Account No. 1090453
Serial No Status
Location
Brand
Type Size
YTD Cons
33050854 a Active
00
b Badger
w Water 1 1
1703
Date
Reading
Code
Consumption
Posted Date
Variance
10/19/2016
2074
aActual
90
11/16/2016
-16%
7/22/2016
1984
a Actual
109
8/16/2016
679%
4/22/2016
1875
a Actual
14
5/25/2016
-6%
1/22/2016
1861
aActual
15
2/19/2016
-87%
10/22/2015
1846
aActual
112
11/20/2015
86%
7/24/2015
1734
a Actual
59
8/14/2015
243%
4/27/2015
1675
a Actual
17
5/19/2015
-9%
1/30/2015
1658
a Actual
21
2/20/2015
-71%
10/24/2014
1637
aActual
68
11/14/2014
9%
7/25/2014
1569
a Actual
63
8/13/2014
297%
4/24/2014
1506
a Actual
15
5/15/2014
-47%
1/27/2014
1491
aActual
31
2/14/2014
-50%
10/23/2013
1460
aActual
60
11/18/2013
-4%
7/23/2013
1400
a Actual
61
8/15/2013
187%
4/24/2013
1339
a Actual
21
5/20/2013
-8%
1/25/2013
1318
a Actual
24
2/13/2013
-44%
10/23/2012
1294
a Actual
42
11/9/2012
-41%
7/23/2012
1252
a Actual
70
8/14/2012
106%
4/23/2012
1182
a Actual
34
5/9/2012
112%
1/23/2012
1148
aActual
16
2/13/2012
-77%
10/24/2011
1132
aActual
72
11/14/2011
-30%
7/22/2011
1060
a Actual
100
8/15/2011
462%
4/22/2011
960
a Actual
17
5/16/2011
-18%
1/25/2011
943
aActual
23
2/11/2011
-68%
10/21/2010
920
aActual
69
11/12/2010
-33%
7/22/2010
851
a Actual
103
8/16/2010
506%
4/22/2010
748
a Actual
17
5/12/2010
-29%
1/21/2010
731
aActual
24
2/12/2010
-42%
7763 NORTH t
Town of North Andover
�ti'•�;;;;::� HEALTH DEPARTMENT
,SSACHUS�<
CHECK #: f/95 DATE:
LOCATION:
H/O NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
Title 5 Inspector $ S�
Title 5 Report $
❑ Other: (Indicate) $
Hea -Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed; constructed; ( ) repaired;
by
- located at
was installed in conformance with the North Andover Board of Health approved plan, System
Design Permit # datedl "I 7 with an approved design flow of y`lU
gallons per day. The materials used were in conformance with those specified on the approved
plan; the system was -installed in accordance with the provisions of 310 CMR 15.000, Title 5 and
- - — local regulations, and the final grading agrees substantially with the approved plan. All work is
_. -accurately represented on the As -built which has been submitted to the Board of Health.
Installer:
Design E
Date: &—/6 zc�g*
Date:
Mi 1'11)pgl
------- ------
Or. f,
5wcw�
Form No. 4
Town of North Andover, Massachusetts
BOARD OF HEALTH
Nov. 17 19 97
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed (x ) or repaired ( )
by Bill Sawyer
INSTALLER
at Lot 5 Windkist, North Andover, MA 01845
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. 976 dated Nov. 3, 19 97
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH ENGINEER
a
North Andover Health Department
(ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 75 Windkist Farm Road MAP: 109 LOT: 0051
INSTALLER: Bateson Enterprises Inc. —Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
PUMP CHAMBER
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑
Watertightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
DISTRIBUTION -BOX
❑ Installed on stable stone base
❑ H-20 D -Box
❑ Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
❑ Observed even distribution
❑ Speed levelers provided (not required)
❑ Schedule 40 PVC Pipe
Comments:
SOIL ABSORPTION SYSTEM (General)
❑ Bottom of SAS excavated down to C soil layer,
as provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑ 40 Mil HDPE barrier installed
❑ Laterals installed and ends connected to
header (and vented if impervious material
above)
❑ Elevations of laterals and chambers installed as on
approved plan
❑ Retaining wall (boulder / concrete / timber/ block)
❑ Final cover as per plan
Comments:
'' Application for Septic misposal S�tsteraT -3 -- ! '7
Construction Permit - TOWN OF TODAY'S DATE
NORTH ANDOVER, MA 01845 � 2501.00
oo - Compll onent
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
pair or replace an existing system component —What?
A. Facility Informations ✓ e�5
Address or Lot #
Cityfrown s . Oq
2: *TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump ravity (choose one)
*"11` pump system, attach copy of electrical permit to appltcation* p T U
➢ [9-Comrentional System (pipe and stone system)
➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
➢ ❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
!f yes, does plan specify make and model of filter? YES = (no further info. needed)
.NO = (installer must specify brand of filter before DWC issuance)
WAatis the Make?
2. Owner Information
what is theMoaiaV
Name
Address (if different from above)
IJUa ,fit-.
Citylrown State Zip Code
Telephone Number
3. Installer Information
Name Name of Company 111 AFC LLA WAD
4` Q _ ANDOVER, &1A ,181 o
Address -'
Cityrrown State Zip Code
Telephone Number (Cell Phone # if possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
i
Telephone Number (Best # to Reach)
&, I 1 0 /iixy -v s�,�'� Application for Disposal System Construction Permit • Page 1 of 2
y'
TODAY'S DATE
$,250.00 T Full Repair
$'125.00:- Component
PAGE 2 OF 2
A. Facility -Information continued....
5. T e'of Buildin : esidential Dweilin or Co
-. Yp 4 g ❑ mmercial
B. Agreement
The underslgned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system In accordance with the Pro v/sions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regu/at/ons for the Town of
North Andover, and not to place;the system Cn operatlon unt11 a Certlficate of Compliance has
been Issued this Board of Health.
• Name
Date
App
of Health
°i�
Date o2(
Application Disapproved. for the following reasons:
For Office Use Only
1 .. FeeAttached?:
• . �J
lqoj
'iTlf ik • i i 'R G iii • I • G
- 5
No
No
No
No
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(ifai et's I a Aad dated
Dtted _ 3
I undes&taad the W"Wwlag► Lwugadosts fart a agement of this project:
le I
i. As the htat I aas.obligated ip obdda alipmW'ta tad Boatd cf Htd& approved ptmpft '
�petfi m as any:morh da a shm .I M= have tbgrjjftmdm&as,WftucM&m liteibm sand
2. As flia iaso: :I, iiia eatt any a di� I£
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As -ba
a ox fat e -M salmi •kyjapm the must
ba itibisiitaed e.8oltrd`of FYaa ,aft: firm lilac. `IaamliQr must
preat:at f+er flakvecdcim tb it ",ftv is f raedy sd able tri
.• � � � $totetaller trust � • ` -.• . ! . •, .
���� ������ en�plttc: Iustaitec iiocs not
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the matnites;f tine Ftusi P t'� �� shd i atri tired
iD pktethe
Auv=30XVAM am am
5.. Ab the.�at�iltet;•I tthderataitii , I titin =am
cx•af
Dealt thrtt.epxerchwait c�ft �.t,bsep i+evcLe
� P�rl�a�'bpBot;etofof�stt�ravas • . .
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P.I.
F.I.
Commonwealth of Massachusetts
BOARD OF HEALTH
North Andover
Map -Block -Lot
109.00051
---------------------
Permit No
BHP -2017-0327
-----------------------
FEE
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted --------------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System.
at No 75 WINDKIST FARM ROAD
$175.00
----------------
-------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -20177032 Dated February 21, 2017
-----------------------------------------------------------------
Issued On: Feb -21-2017 BOARD OF HEALTH
Commonwealth of Massachusetts Map -Block -Lot
109.00051
BOARD OF HEALTH -----------------------
North Andover
CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair)
by
Installer
at No 75 WINDKIST FARM ROAD
----------------------------------------------------------------------------------------------------------------------------------------------------------
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 -2017-032 Dated February 21,-2017
------------------------------------- --
-----------------------------------------------------------------
Printed On: Feb -21-2017 BOARD OF HEALTH
Commonwealth of Massachusetts Map -Block -Lot
109.00051
BOARD OF HEALT Permit No
BHP -2017-0327
North Andover' zi
��y
FEE
$175.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted 10�Z`�,SQ✓}-QQnwi___%�_7`QQ__tp�'j,QO� C
to (Repair) an Individual Sewage Disposal System.
at No - 75 WINDKIST FARM ROAD
-------- -
as shown on the application for Disposal Works Construction Permit No. BI]V_n 17-032 Dated e ' ary 01
---- -- - ------ -----�
--------------------
Issued On: Feb -21-2017 BOARD OF HEALTH
----------------------------------------------------------------------------------
t ryORTH
O tt ��o �y,1•C
,SS^GHUSEt
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 3
ol/ 'S 19 97
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant �—B/6t 5AL6y's,e
NA/ME l ,1 A
Site Location_ G6 > Qs 1���v�K/1S%
T
Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. 476
CHAIRMAN, BOARD OF HEALTH
w1d W01J QN0)-15 S�WON aNl l jD �I:-iG!'11i I ��
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: & —,31 — 9Z CURRENT INSTALLER'S LICENSE#
�� ff
LOCATION: 20
LICENSED INSTALLER: i �9 ar r
SIGNATURE: 7--,::g"TELEPHONE#
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
Foundation As -built?
Administrative Use Only
Yes `-''_ No
Yes
No
Floor plans on file? Yes No
Approval Date: 11
FORM U - VERIFICATION 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: l �l'�LSP 1 5 GL � Phone Z 7
LOCATION: Assessor's Map Number C Parcel 3�
Subdivision //LGt'�/� //- Lot (s) 'Sr
Street A&4VlZe-5 ig2l�! S f�C St. Number
77 DA7O OF GENTS:
Conservation Administrator
Comments
Use Only************************
Date Approved �
Date Rejected
Town lanner
Date
Date.Rejected
Approved R 7
Comments
Food Inspeectorr-Health
Date
Date
Approved
Rejected
%
--.�i��'C.C�
Septic Inspector -Health
Date
Date
Approved
Rejected
/
Comments
Public Works - sewer/water connections
- driveway permit�� GJ -5
Fire Department yZLJ h q U(,,4 ke- (MC t .L� r
eceived by Building Inspecto Date
pORTbp
o c
_ 9
i �
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SSAc"UsE�
Town of North Andover, Massachusetts
BOARD OF HEALTH
e
DESIGN APPROVAL FOR _
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
r
Applicant Test No.
_ Site Location
Reference Plans and Specs.
ENGINEER F DESIGN DATE -.
-.Permission is granted for an individual -soil absorption sewage disposal, system to Ge FfiM -ed.
in accordance with regulations of Board of Health.
v CHAIRMAN; BOARD OF HEALTH
Fee `_. - Site System Permit No.
FORM 11 - SOIL EVALUATOR FORM
_ Page 1 of _
Date:
_11j�&7
No.
Commonwealth of Massachusetts
Norte 14v,j . Massachusetts
A for On-site Sewa e Di
Date :1qi1L/a
Performed By. ...../?..
Witnessed By:
/ LC- �I.5 Adams. an' f d `T / iii r, " f ��,o� Address o< W>'ndk-rs�
Loi /
13ost� .57— �� Telephone IVO. Rnd��u, o
New Construction 5? Repair ❑
Office Review
Yes
Published Soil Survey Available: No ❑ d L
/ . /5.1�.�� Soil Map Unit
�� ................ Publication Scale t _ .. _.....................
Year Published ......................................
f'iU�'1?.. oil Limitations
Drainage Class Wt 11 S ❑
2 --'Yes
Surficial Geologic Report Available: Npublication Scale
Year Published
_, ..........................
Unit.....................................................................
Geologic Material (Map .................... .
LandformY..44WI%...................................................................
Flood Insurance Rate Map:
Above 500 vear flood boundary No U����Y//es -
year flood boundar}' No 2' es
Within 500 y ❑
❑
Within 100 year flood boundary Noes
.. .............
Wetland Area: ma unit)
......................................
Map (map .....
National Wetland Inventory .......................................................... .
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS):
Month
Range :Above Normal []Normal ❑Belc�•i Normal ❑
Other References Reviewed:
DEP APPROVED FORM . 12107195
FORM 11 - SOIL EVALUATOR FORM
Page -"'of 3
Location Address or Lot 1Jo.�%✓14�IS �Gt/�'►� . UGt
On-site Review
Deep Hole Number
Date: ?lY/f 7 Time: Weather
Location (identify on site plan)
Land Use ... Slope (%) Surface Stones
Vegetation
Landform
Position on landscape (sketch on the back)'
Distances from:
Open Water Body feet Drainage way feet
Possible Wet Area feet Property Line feet
Drinking Water Well feet Other
DEEP OBSERVATION HOLE _OG'
DP
Soil Horizon Soil Texture Soil Color Soil
Other
Surtes) (USDA) (Munsell) Mottling (Structure, Stones, BouldGraveers, Consistency, 9,;
n -� A Loam.
Loam
Loa-v►�
• �ra� S l8
t t-DISPOSALAR2,1
L (�
Parent Material* (geologic) !�_ DeMMoBedrock: — ��
Depth to Groundwater: Standing Water in the Hole:
nr� Weeping from Pit Face:
Estimated Seasonal High Ground Water:
DEP APPROVED FORM • 12107/95
FORM 11 - SOIL EVALUATOR FORA
Page ''oC 3
Location Address or Lot No.�it�i✓1Q�K
On-site Review
Deep Hole Numbergl-'S / Date: 11497
Location (identify on site plan)
Land Use .. Slope (%}
Time:
Surface Stones
Vegetation -
Landform .
Position on landscape (sketch on the back)
Distances from:
Open Water Body feet Drainage way
Possible Wet Area feet Property Line
W II � feet Other
feet
feet
Weather
Drinking
Water e
DEEP OBSERVATION
HOLE
_OG'
Soil Texture
(USDA)
Soil Color
(Munsell)
to I?-
Soil
Mottling
Other
(Structure, Stones. G Boulders, Consistency, °ro
Ce"�
Depth from
Surface (Inches)
Soil Horizon
_
a
L s
L5
!0 V ►2
r-6VYL tet/
4Ito
la -36
8C
LS
.2,s Y
Gvamu.l4,f,,
`+/6
3641
C
Med-
eo6Ws-<-
a +s �
lVlr s s � f i u. 6 �.
sed
qly
ye s
M&nY Cobb l
Corn12utPd L �
OF 2
EQUIRMI tt
t
MINIMUM
Parent Material- (geologic)
T(
C.- �—
®
DepthtoBedrock:
Weeping from Pit Face: ��
Depth to Groundwater:
Standing
Water in the Hole:
!`
Estimated Seasonal
High Ground Water:
DEP APPROVED FORM - 11107/95 �
FORM 11 - SQIL L � ALU: � i Uk� t'U1QV1
Pare 3 of 3
Location Address or Lot No. _r? - I& , '�'/
eteMination for SeasonWater Fable
Method Used'
Depth observed standing in observation hole inches
�! Deotn weeping from side of observation hole
inches
!_Depth to soil mottles 36 " inches
Ground water adjustment ................ feet
Reading Date Index well level
index Well Number ........
g
Adjusted around water level
Adjustment factor 1
Death o` Naturally Occurrino Pervious Material
Does at least four feetof naturally
osedvforithe soil absorption material
system? m all areas
observed throughout the area prop
If not, what is the depth of naturally occurring pervious material?
Zertificatior
G' �-fthe soil I have
1 certify that on j� 1 Go veonmental Protection edction and that the above analysis
aGproved by she Department of �n
was performed by me consistent with the required training, expertise anti experienc:
described in 310 CMR ...017.
Date
Signature l
DEP APPROVED FORM - 1:/07195
FORM 12 - PERCOLATION TEST
Location Address or Lot No. S— (/��`/?��GfS'T� /�— X1&4
COMMONWEALTH OF MASSACHUSETTS
!V o . &do IA- , Massachusetts
Percolation Test*
Date:.... S 121ri% Time:. .:
6
Observation Hole #
Depth of Perc
_
Start Pre-soak
la
End Pre-soak
/A 3 .7
2V
Time at 12"
1d ; 3 7
10;
Do 2
Time at 9"
J� , S
102�
Time at 6"
J Z
l
Time (9"-6")
i/
�� f
Rate Min./Inch
/ .
* Minimum of 1 percolation test must bo perfor� � Feu in both tr ie primary area AND
reserve area.
Site Passed Site Failed ❑
1....................................................:......................................._._...................
Performed By: �, O'COLine11I/S75Gt�s I
Witnessed By:
Comments:
DEP APPROVED FORM - 12/07/95