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North Andover Board of Assessors Public Access ; . Page 1 of 1
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Sales
Summary
Residence
Detached Structure
Condo
Commercial
Comparable Sales
Tova of North A & ove
ID_cwirdof Assessors
Parcel ID: 210/105.A-0030-0000.0
SKETCH
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UjProperty
Record Card
Community: North Andover
PHOTO
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Location: 79 BROOKVIEW DRIVE
Owner Name: CAIN III, EDWARD A
KATHRYN J CRECELIUS
Owner Address: 79 BROOKVIEW ROAD
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 9 - 9 Land Area: 1.03 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3130 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 760,400 776,200
Building Value: 483,000 512,000
Land Value: 277,400 264,200
Market Land Value: 277,400
Chapter Land Value:
LATEST SALE
Sale Price: 499,895 Sale Date: 02/01/1999
Arms Length Sale Code: Y -YES -VALID Grantor: BROOKVIEW COUNTRY
Cert Doc: Book: 05330 Page: 0028
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1180779 3/10/2008
MAP # LOT # J
PARCEL # STREET �i C
CONSTRUCTION APPRO
HAS PLAN REVIEW FEE BEEN PAID? ES NO
PLAN APPROVAL: DATE �� APP. BY D
DESIGNER: T -CS 477-1 PLAN DATE LO Q
CONDITIONS
WATER SUPPLY: TOWN WELL
WELL PERMIT
WELL TESTS:'
f
PLUMBING SIGNOFF.B
COMMENTS:
DRILLER
CHEMICAL DATE APPROVED
DATE APPROVED
BACTERIA II ` DATE APPROVED
WIRING SSIGNOFF
FORM U APPROVAL: APPROVAL TO ISSUE YES NO
DATE ISSUED lo�%I7 BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: BY:
ti
f
s
SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED? NO
TYPE OF CONSTRUCTION: y NE REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YE NO
DWC PERMIT PAID? p� YES NO ?
DWC PERMIT NO. /�� INSTALLER:�.� �F��/
BEGIN INSPECTION YE NO:
EXCAVATION INSPECTION: NEEDED:
PASSED GD BY
CONSTRUCTION INSPECTION: NEEDED:
AS BUILT PLAN SATISFACTORY: YES:>
APPROVAL `i'O BACKFILL: DATE: / D�Q_BY
FINAL GRADING APPROVAL: DATE i� �o %'� BY
� v
FINAL CONSTRUCTION APPROVAL: DATE: BY
Commonwealth of Massachusetts RECEIVED
City/Town of ocT 2.6 1013
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
DEPARTMENT
HEALTH
DEP has provided this form for use* by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using -this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house4py Rig ea of house Left / right side of house, Left /
Right side of building, Left / Right front of buil Ing, Left / Right rear o building, Under deck
Address t—T ct
City/Town ` State
Zip Code
2. System Owner.
Name
Address (if different from location)
r
CitylTown State/ -)e
Telephone Number
i
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Date 2. Quantity Pumped:
Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? E] Yes No If. yes, was it cleaned? . ❑ Yes ❑ No.
5. Conditio os�te
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
/G.L,S.Pj _ Lowell Waste Water
t5form4.doc• 06/03
Date
System Pumping Record • Page 1 of 1
i
M RTN ; 5503
ti • ' 09
• TAwn of North Andover
•� :.
1PHEALTH DEPARTMENT
,SSCHU`+tt
CHECK #: _ �1`. DATE: /1-1�
LOCATION:
H/O NAME:
CONTRACTOR NAME:�`�//i�ff� , yftr
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
$
19
Title 5 Report
$.
❑ Other: (Indicate) $
Halth Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
y,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessme
1 "Bcookyl �Wr
Owner
information is
required for
I Vt
every page.itylrown
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
_ I�
ICI
C
(Coto(
,M-5Zo11
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.
A. General Information
1. Inspector:
C
Name of Inspector C4! G r 1 e
Company Name
11. ouX
b U k (_
-4—,e `e n ) \ Ut
Company Address -r—e
City/Town Stale ( Zip Code
-7 559/
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
5� Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 09108 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
I rookVIPW�Y
Property Address
Owner's Name
City/Town
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.
Comm
B) System Conditionally Passes:
C 6 M MA V.d �11 0,�
?A6 4( 1�1
❑ 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 a following statyements. If "not
determined, " please explain.
The septic tank is metal and over 20 years old" or the se is tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or filtration or tank failure is imminent. System
will pass inspection if the existing tank is replaced w' a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection If ,Kis Is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is leXs than 20 years old is available.
❑ Y ❑ N ❑ P6 (Explain below):
tsins • osioa
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
I R `Jcoolcv1�w-:�)r
Property Address
Owner's Name
City/Town
B. Certification (cont.)
B) System Conditionally Passes (cont.);
State Zip Code 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑X (Explain below):
❑ The System required pumping
system will pass inspection if (
❑ broken pipe(s) are ro
❑ obstruction is
4 times a year due to broken or obstructed pipe(s). The
,al of the Board of Health):
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by thSff6ard of Health in order to determine if
the system is failing to protect public health, safetyorthe environment.
1. System will pass unless Board of HeW determines in accordance with 310 CMR
15.303(1)(b) that the system is not f tioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy ' ithin 50 feet of a surface water
❑ Cesspool opKr1vy is within 50 feet of a bordering vegetated wetland ora salt march
t5ins • 09/08
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
:) 91 , codk,VI PLim r
is Name
Cityfrown
B. Certification (cont.)
State Zip Code Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
deterimes 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,,SKS' is within
100 feet of a surface water supply or tributary to a surface water sup Y.
❑ The system has a septic tank and SAS and the SAS is within a ne 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is thin 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the S 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 alysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the pr ence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that n ther 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
❑ d
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Q�
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
1 ❑
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
t5ins • 09/06 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
Property A ress
Owner
Information is Owner's Name
required for
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:
El LJ 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.
❑ 2"' Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ D" Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Lam' 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.]
❑ Er This system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ d 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 urface drinkiing water supply
❑ ❑ the system is within 200 t of a tributary to a surface drinking water supply
❑ ❑ the system is loc d in a nitrogen sensitive area (Interim Wellhead Protection
Area - IWPA a mapped Zone II of a public water supply well
If you have answered "ye " o any question in Section E the system is condidered a significant threat,
or answered "yes" in ction D above the large system has failed. The owner or operator of any large
system consider a significant threat under Section E or failed under Section D shall upgrade the
system in a rdance with 310 CMR 15.304. The system owner should contact the appropriate
regiona ice of the Department.
t5ins • 09/08 -
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 5 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
� 9 12,, r6i /I k, ifI-fw'Df
Property Address
Owner's Name
City/Town
C Checklist
State Zip Code Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
G ❑
❑ d
9' ❑
❑ L?
❑ ❑
2' ❑
2 ❑
d ❑
9 ❑
9 ❑
d ❑
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?
This 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): T Number of bedrooms (actual): -/
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins • 09/08 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
a
�l
cc) c) ](--v e war
w Property Address
Owner
Information is Owner's Name
required for
every page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected? PIA
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail: bj 1_ l I V
P+C
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR /15.20:Basis of design flow (seats/perso
Grease trap present?
Industrial waste holdingnk present?
Non -sanitary wasteeischarged to the Title 5 system?
Water meter readings, if available:
3
❑ Yes E No
❑ Yes Ef No
❑ Yes ❑ No
❑ Yes E3/No
_S�� tY-�tm�uci
V14 a.
❑ Yes ,d No
Dat
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
l5ins • 09/08
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 7 of 17
LN
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property
Owner's Name
City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
State Zip Code Date of Inspection
General Information
Date
Source of information: `� SJ bw V3 e,<-
Was system pumped as part of the inspection? 12( Yes ❑ No
If yes, volume pumped: I s-0 O & ],-
gallons
How was quantity pumped determined?
Reason for pumping: u� tlk �✓ J{'uJ Ik Type of System:
E Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 8 of 17
lidl—
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l
19 I' r--06kv1 P WD f
Property
Owner's Name
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
' Q 13DH
Were sewage odors detected when arriving at the site? ❑ Yes Sa" No
Building Sewer (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron [A 40 PVC ❑ other (explain) N J A
Distance from private water supply well or suction line: A)
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Up
V �VGC
Septic Tank (locate on site plan):
Depth below grade: 1 ,
feet
Material of construction:
E concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: ,
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: SOD CIA- ly �—
Sludge depth �•
t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 9 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
' q �( C -D 0
Property Address
Owner's Name
City/Town
D. System Information (cont.)
State Zip Code Date of Inspection
Septic Tank (cont.)
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 / -T-
Distance
Distance from bottom of scum to bottom of outlet tee or baffle
j
How were dimensions determined? �I UGl Ci 'j U (Il
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
4�;7RO�l ic +,q k 0- (YT,4jW /9 (z)1J-9(- so,0--e W66 —jQQ
eA) 5UC a�� �' e �e5
�QyV-\r cd V1
1 iA
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
Distance from top of scum
Distance from bottom of IW
Date of last pumping:
feet
❑ fibergi4ss ❑ polyethylene ❑ other (explain)
of outlet tee or baffle
to bottom of outlet tee or baffle
Date
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
coo lc w ew�r
M Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or ball 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 ❑ po ethylene ❑ other (explain)
Dimensions:
Capacity:
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm/float witches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
l5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 11 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
Property
Owner's Name
City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
C�lois q- P rbv,6-e5 ebi,4 - Itwo- n,MRI
ov- v ti vv� u CC r -�
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
Comments (note condition of pump chamber,
/ ❑ Yes ❑ No
❑ Yes ❑ No
of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 12 of 17
M
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`10A
Property
Owner's Name
City/Town
D. System Information (cont.)
Type:
❑
leaching pits
❑
leaching chambers
❑
leaching galleries
leaching trenches
❑
leaching fields
❑
overflow cesspool
❑
innovative/alternative system
State Zip Code Date of Inspection
number:
number:
number:
number, length:
number, dimensions:
number:
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
A5t,115 Av—o,v dY)
C3 V v1Aj d � l CA V1 5 C) -� � �d� rq � 1 �, a � � vY e o� s-,QrV,,ed
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 Ll Yes L No
(t5ins • 09/08
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 13 of 17
�M
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form Not for Voluntary Assessments
11 q 01 ro 6
Property Ad ress
Owner's Name
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): /
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs
etc.):
failure, level of ponding, condition of vegetation,
(t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 14 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
Property AdcTress
Owner's Name
City/Town
D. System Information (cont.)
State Zip Code 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:
2(hand-sketch in the area below
❑ drawing attached separately
(t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 15 of 17
e
�M
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
IQ (�, rovl<,I/I-eL,) ADf
Property
Owner's Name
City/Town
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
State Zip Code Date of Inspection
4& v
feet
Pse indicate all methods used to determine the high ground water elevation.:
d- Obtained from system design plans on record
If checked, date of design plan reviewed:
ae
❑ 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:
Before filling this Inspection Report, please see Report Completeness Checklist on next page.
(t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 16 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
, ,� &061(V1,eL,)T(-
Property Address
Owner's Name
City/Town
State Zip Code Date of Inspection
E. Report Completeness Checklist
dInspection Summary: A, B, C, D, or E checked
dInspection Summary D (System Failure Criteria Applicable to All Systems) completed
LJ System Information - Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
T5ins • 09108
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 17 of 17
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p Town of North Andover
`'•'� HEALTH DEPARTMENT
'sswcHust4
CHECK #:
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 Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic -Disposal Works Installers (DWI)
itle 5 Inspector ���DO.�� $
❑ Title 5 Report $
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner's Name
No Andover
City/Town
MA 01845
State Zip Code
1/30/08
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:
Willi
When filling out A. General Information
W
forms on the
computer, use 1. Inspector:
only the tab key
to move your Benjamin C. Osgood Jr.
cursor - do not Name of Inspector
use the return
key. New England Engineering Services, Inc.
Company Name
tcl 1600 Osgood Street Suite 2-64
Company Address
No. Andover MA 01845
�f07 City/Town State Zip Code
978-686-1768
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
G 1 9
—3®-0cz3
if rspectoX Signature Date
The system inspector stuff 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.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner's Name
No Andover MA 01845 1/30/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A)) System Passes:
211-1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
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
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner Owner's Name
information is
required for No Andover MA 01845 1/30/08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ 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:
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
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.
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15
MW
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner's Name
No Andover
City/Town
B. Certification (cont.)
MA 01845 1/30/08
State Zip Code Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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
❑
Ea/,
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
a-
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
13 -*1
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
E
Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
EEr
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
TITLE 5 FORM 2007.DOC • 08/06
- Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner's Name
No Andover MA 01845
City/Town State Zip Code
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
1/30/08
Date of Inspection
❑ 21*- 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.
❑ Di 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.]
❑ 2,- The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ 2,-- 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
❑ [p� the system is within 400 feet of a surface drinking water supply
❑ 0the system is within 200 feet of a tributary to a surface drinking water supply
❑ Ell-' 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.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner's Name
No Andover
CityfFown
C. Checklist
MA 01845 1/30/08
State Zip Code 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?
R"*"
❑
Has the system received normal flows in the previous two week period?
❑
zll*�
Have large volumes of water been introduced to the system recently or as part of
this inspection?
2/
❑
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?
[9
❑
Was the site inspected for signs of break out?
[9
❑
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)]
TITLE 5 FORM 2007.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner Owner's Name
information is
required for No Andover MA 01845 1/30/08
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): - ` Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): L4 Ko 61 PD
Number of current residents: Z
Does residence have a garbage grinder? DI Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes �] No
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes r;71 No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe):
Gallons per day (gpd)
Date
❑ Yes No
G✓ r .•�—
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
TITLE 5 FORM 2007.130C • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner Owner's Name
information is
required for No Andover MA 01845 1/30/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
5)11316 L) ?toz- ROVne-C—rit1t—
gallons
❑ Yes C, No
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ 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 5d No
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner Owner's Name
information is
required for No Andover MA 01845
every page. City/Town State Zip Code
1/30/08
Date of Inspection
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron [A 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
❑,oncrete ❑ metal
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) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
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?
N
M
/YyC#4Sy PC -C-7-7c IC
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System ° Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 79 Brookview Drive
Property Address
Edward A. Cain
Owner
information is
required for
every page.
Owner's Name
No Andover
City/Town
1/30/08
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.):
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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 I ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 79 Brookview Drive
Property Address
Edward A. Cain
Owner
information is
required for
every page.
Owner's Name
No Andover MA 01845
City/Town State Zip Code
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
1/30/08
Date of Inspection
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
V1
Depth of liquid level above outlet invert - U
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evvi�idence of leakage into or out of box, etc.):
2-K (AJ U &,>o c0AJ.fl1'n0nJ- A ,> F,—Jn-e-K D4" Sir-�a� c,4,QRy0.ivL
_f? is ► $cJ -1`1 0 y EQU -41
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
❑ Yes ❑ No
❑ Yes ❑ No
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 79 Brookview Drive
D. System Information (cont.)
1/30/08
Date of Inspection
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:
Type:
Property Address
❑
Edward A. Cain
Owner
Owner's Name
information is
required for
No Andover MA 01845
every page.
City/Town State Zip Code
D. System Information (cont.)
1/30/08
Date of Inspection
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:
Type:
Oi�- TQ9PjcKE-r SAJow
❑
leaching pits
❑
leaching chambers
❑
leaching galleries
leaching trenches
❑
leaching fields
❑
overflow cesspool
❑
innovative/alternative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions:
number:
F71 ^S3 f
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
f yZiWA-
Oi�- TQ9PjcKE-r SAJow
!A" c2Gi
/N0 E%j VI, CC
b
o R
V Ny-s 11A% -,V
EG- Ep )Y�r-ncJ N
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner Owner's Name
information is
required for No Andover MA 01845 1/30/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
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 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner
information is
required for
every page.
Owner's Name
No Andover
City/Town
MA 01845 1/30/08
State Zip Code Date of Inspection
D. System Information (cont.)
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.
nts�A���S
13, -J>�s�
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Brookview Drive
Property Address
Edward A. Cain
Owner's Name
No Andover
Cityrrown
D. System Information (cont.)
Site Exam:
(Check Slope
[-Surface water Aj,>w c
[-Check cellar N.9 .riJ AA
[]'Shallow wells 0.9 'C
Estimated de th to round water•
MA 01845 1/30/08
Date of Inspection
p 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:
You must describe how you established the high ground water elevation:
157' jsTt w. �es,N.•e f -j q�� L ,c �. 2J.� Nt1
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Monday, March 10, 2008 10:55 AM
To: Irmottola@andoverliving.com'
Subject: Title 5 Inspection Report - 79 Brookview Drive
Here is the Title 5 Report.
Pamela DelleChiaie
Health Department Assistant
-----Original Message -----
From: noreply@yourcopier.com [mai Ito: noreply@yourcopier.com]
Sent: Monday, March 10, 2008 11:51 AM
To: DelleChiaie, Pamela
Subject: Message from KMBT_600
CON
11..1
SKMBT_600080310
10510.pdf
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EX. VENT
9
445649 S.F.
1.03 Ac.
23'
EX. D -BOX
EX. 1500 GAL,
IUI SEPTIC TANK
EX. 3' X 53' TRENCHES
116-45
79
24386'
ELEVATIONS TAKEN AT TOP OF PIPE
m
L=51.98'
R=125.00
IDRIV
SWING TIES
TOP OF FOUNDATION: ►' AAAAA COMPONENT COR A COR B
OF '� SEPTIC TANK (CENTER)
PIPE � DWELLING: • �y,�P�T Mgss9c p -BOX (CENTER)
TANK IN: _ • � JFiN y
END PIPE: C
TANK OUT: 135.57 , e IR ►
D -BOX IN: 135.39 No 0052 � ► END PIPE: D
D -BOX OUT: 135.24 (ALL)0 '9F� STER�� �`'�
END PIPE - A: 134.88 ►ass/0 p�EN��a 7
END PIPE - B: 134.90 _
END PIPE - C. 134.81
AS -BUILT SEWAGE DISPOSAL
SYSTEM PLAN
LOT 5 BROOKVIEW DRIVE
NORTH ANDOVER, MASS.
PREPARED FOR
BROOKVIEW COUNTRY HOMES
P.O. BOX 531
NORTH ANDOVER, MASSACHUSETTS
MARCHIONDA & ASSOC., L.P.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE., SUITE I
STONEHAM, MA. 02180
(617) 438-6121 Cog) y39
SCALE: 1=20' DATE: 10/27/97
M & A FILE No.: 351 - 22
OCT — 3 1— 9 7 F R I 1 4@ 2
n
M44,649 S.F.
1.03 Ac.
py W
EX. V NT
23'
Li_ 116.45'
243.86'
EX. 3' X 53' TRENCHES
BROOKVIEW
ELEVATIONS TAKEN AT TOP OF PIPE
TOP OF FOUNDATION:
PIPE 0 DWELLING: _M
TANK IN: ------
TANK OUT. 135.57
D -SOX IN: 135.39
D -BOX OUT: 135.24 (ALL)
END PIPE — A: 134.88
END PIPE — 8: 134.90
ENC PIPE - C: 134.81
AS -BUILT SEWAGE DISPOSAL
SYSTEM PLAN
LOT 5 BROOKVIEW DRIVE
NORTH ANDOVER. MASS.
PREPARED FOR
BROOKVIEW COUNTRY HOMES
P.O. BOX 531
6 Vii'
EX. D-HOX
EX. 1500 GAL..
SEPTIC TANK
L=51.98'
R=125
DRIVE
SWING TIES
COMPONENT CORA COR B
SEP C TANK
D --BOX
END PIPE. C
ENO PIPE: D
END PIPE: E
n
ri
(CENTER)
(CENTER)
MARCHIONDA & ASSOC., L.P.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE, SUITE I
STONEHAM. MA. 02180
(617) 438-6121
SCALE: 1-* 36 DATE: 10/27/97
M & A FILE No.: 351 - 22
"jj� + S A t Uft k R S b (PQ_k 1^4'-4UC "4
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Pi f s -e CA t f
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,SSACMUSEA
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant t�t/� Test No.
Site Location
Reference Plans and Spec
ENGINEER
I
1[:1
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
4 0/
Fee—66
CHAIRM , BOARD OF HEALTH
Site System Permit No. 04
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: / Dhsh; CURRENT INSTALLER'S LICENSE#
LOCATION: ZC) r Jam—' ��_06 IZ V l f QCs 1�60_d
LICENSED INSTALLER: ��-'"j-�iL (ce_/V
SIGNATURE: &Z11 TELEPHONE# 6 9 % —2 % 2
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes ,, No
Foundation As -built? Yes No �� 1,0116 \
Floor plans on file? Yes No
Approval r_ � /�/�A Date: /Q 11 /�
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INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Hoards 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************/*C**{**
APPLICANT:R)f4o Krrl e� �OGN %2t 0^1t S Phone blq
LOCATION: As_essor's Mao Number /yR Parcel 3 7
Subdivision Be -o6 tyic o Lot (s)
Scree} 6edd ellie h% f.�P► ✓ � St. Numcer
Use
771,
DATI NS 0 OWN AGENTS:
Date Approved
Ad-_nistratcr Daze Rejected
C c-, - e nc s �AnZ/Ai(4-l iLh, d S Lu ) I h ) d c)
Con:^er.�s
Crl;s - Se! 7er,'wazer connections
Daze Ancrcve•d
Daze Resected
Date
Daze Rejected
driveway permit
Fire Depart=en--
Received by Building Inscector Data
Cx'-( uY- a
Date
Apprcved
�f �
Town
Planner
Daze
Rej ectad
Con:^er.�s
Crl;s - Se! 7er,'wazer connections
Daze Ancrcve•d
Daze Resected
Date
Daze Rejected
driveway permit
Fire Depart=en--
Received by Building Inscector Data
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCOTT
Director
June 18, 1997
Mike Rosati
Marchionda & Associates
62 Montvale Ave., Suite 1
Stoneham, MA 02180
RE: Brookview Circle
Dear Mike:
30 School Street
North Andover, Massachusetts 01845
This letter is to inform you that the proposed septic plans for Lots 2, 4, 5,
6, 7, 8, and 10 Brookview Circle have been approved.
_ If you have any questions, please do not hesitate to call the Board of
Health office at the number below.
Sincerely,
��
Sandra Starr, R.S.
Health Administrator
cc: Wm. Scott, Dir. CD&S
File
Dave Kindred
COWURVA770N 681t_4510 IMALT4S. 699-9540 ➢T. ar?NT*1C, 6R8-4S7S
SEPTIC PLAN SUBMITTALS
LOCATION: Z
NEW PLANS: YES $60.00/Plan
REVISED PLANS: qli $25.00/Plan
DATE:, �l
DESIGN ENGINEER: �-���
When the submission is all in place, route to the Health Secretary
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCOTT
Director
May 30, 1997
Marchionda Associates
62 Montvale Ave.
Suite #1
Stoneham, MA 02180
30 School Street
North Andover, Massachusetts 01845
Re: Lot 95 Brookview Circle
To Whom it May Concern:
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
If new plans satisfactorily addressing all the following issues are submitted to the Health
Department by June 12, 1997, then approval for the plans should be given by June 19,
1997. -
1. Only 2 copies of plans submitted. (N.A. 6.01)
2. Elevations of perc tests missing. (N.A. 6.02j)
3. Reserve not 4 feet from primary. (N.A. 2.23)
4. Vent on lines missing. (310 CMR 15.251)
5. No benchmark within 75 feet of system. (3 10 CMR 15.220(q))
6. Please label foundation drain.
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
cc: David Kindred
.CONSPRYATION 688-9510 HEALTH 688-9541' PLANNING .688-9535
1e
May 3 0, 1997
Marchionda Associates
62 Montvale Ave.
Suite #I
Stoneham, MA 02180
Re: Lot #5 Brookview Circle
To Whom it May Concern:
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
If new plans satisfactorily addressing all the following issues are submitted to the Health
Department by 61/ Z , then approval for the plans should be given by
r
lr.Y'.'` Only 2 copies of plans submitted. (N.A. 6.01)
L. -*2' Elevations of perc tests missing. (N.A. 6.02j)
C,--< Reserve not 4 feet from primary. (N.A. 2.23)
L,4 -!--Vent on lines missing. (310 CMR 15.251)
Z,,S'-No benchmark within 75 feet of system. (310 CMR 15.220(q))
(_6 -'Please label foundation drain.
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R. S.
Health Administrator
S S/cjp
cc: David Kindred
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
DATE -4�9qI
FEE: PERMIT ## 70� DATE RECEIVED -
APPLICANT -1
ECEIVEDAPPLICANT1 Av,!,--- eliV1b,cC1b MAP PARCEL
ADDRESS / LOT # � STREET #
ENG. /rr �61,416/U�� Ileo STREET �(�Cb /�U/�`(CJ 01,C.
ENGINEER'S ADD.
PLAN DATE REV. DATE
CONDITIONS OF APPROVAL
APPROVED
REASONS FOR DISAPPROVAL:
DISAPPROVED
i-jlz-r/4-,ex- 1J err -1110
C
(IV, 14 6' � o
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� . quo UC -AJ,- L5 16
. �f L Z LANG G �DAJ• !7/�/� /,(J
PLAN REVIEW CHECKLIST
ADDRESS S �,�c�,�l//�� ENGINEER
GENERAL /
3 COPIES STAMP LOCUS£ NORTH ARROW
!/ SCALEy
CONTOURS PROFILE LI�(Sc) SECTION &I---- BENCHMARKS SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER `� WELLS & WETS "
WATERSHED?/4//) DRIVEWAY v' WATER LINE FDN DRAIN ? M&P
SCH40 TESTS CURRENT? SOIL EVAL 7n5/3T/
SEPTIC TANK
MIN 150OG C- .17 INVERT DROP 4,-' GARB. GRINDERJ/0 (2 comps +200)
10' TO FDN l/ MANHOLE --' ELEV ✓ GW ---- ## COMPS. I GBy
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET /3(5°D 7 - OUTLET /3 •9D = r /7 ( 2" OR .17 FT) TEE REQ' D? tlO
LEACHING
MIN 440 GPD? c/ RESERVE AREA,(, -'-
4' FROM PRIMARY?� 20 SLOPE
100' TO WETLANDSI-� 100' TO WELLS`- 4' TO S.H.GW (5'>2M/IN)
20'
TO FND &
INTRCPTR DRAINS --'-
RAINS-
400'
TO
SURFACE H2O SUPP
4'
PERM. SOIL
BELOW FACILITY -�--"
MIN
12"
COVERy FILL?1-x(15')
BREAKOUT MET?
TRENCHES
MIN 440 gpdSLOPE (min .005 or 611/100' ) SIDEWALL DIST. 3X EFF.
W OR D (MIN 6') (-� RESERVE BETWEEN TRENCHES? L--- IN FILL? 4""" MUST
BE 10' MIN. 4" PEA STONE?_LZ VENT?_ (>3' COVER; LINES >501)
BOT 7 + SIDE (93,6 = /// '-�) X LDNG 7 = TOT 4*,J 744d
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1996 by S.L. Starr
SEPTIC PLAN SUBMITTALS
LOCATION:
NEW PLANS: ( YES \ i $60.00/Plan
REVISED PLANS: YES $25.00/Plan
DATE:I
DESIGN ENGINEER:
When the submission is all in place, route to the Health Secretary
127.41'
S0411'22»W
OKVIEEW
-'ter---
N04-°11 '72„E
N/F
LOT 6
5
44,649 S.F.
1.03 Ac.
EX. V NT
23E
EX. D -BOX
EX. 3 X 53' TRENCHES SEPTICOOAG KL
55.9' i TOP FN EL=141.43'
[1
39.0'
1 16.45'
243.86'
[DRIVE
43.86'
ELEVATIONS TAKEN AT TOP OF PIPE
TOP OF FOUNDATION: SEE PLAN
PIPE ® DWELLING: 137.60
TANK IN:
V3 515
TANK OUT:
135.57
D -BOX IN:
135.39
D -BOX OUT:
135.24 (ALL)
END PIPE - A:
134.88
END PIPE - B:
134.90
END PIPE - C:
134.81
AS—BUILT SEWAGE DISPOSAL
SYSTEM PLAN
LOT 5 BROOKVIEW DRIVE
NORTH ANDOVER, MASS.
PREPARED FOR
BROOKVIEW COUNTRY HOMES
P.O. BOX 531
NORTH ANDOVER, MASSACHUSETTS
A, 1-- 43.8'
EXIST. FND.
L- 51.98'-3-7 �
R-125 25
43,11
0.99
EX' VEN T
EX' 3'
2 3 55' p
F --
20.3' --
C F F. -C
ELEV. =133.
EX. 1500 GAL.
SEPTIC TANK
rn
46.5'
N0
TYN D
ELEV.
L=8.92'
I
�O
R-175 -°°,
L -85•Z
SWING TIES
COMPONENT
COR A
COR B
SEPTIC TANK
54'
tie'
D --BOX
45'
S0'
END PIPE: C
41.
31
END PIPE: D
e4'
END PIPE: E
q5'
(CENTER)
(CENTER)
MARCHIONDA & ASSOC., L.P.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE., SUITE I
STONEHAM, MA. 02180
(617) 438-6121
REV: 7/6/98 9%lo/q8
SCALE: 1=30' DATE: 10/27/97
M & A FILE No.: 351 - 22
N/F
F.
LOT 6 t'v
23' ----,
COR E
R A
55.9' .
i
l
Approx.
Lncation
of
Driveway
�n
CJ
2
5 'L -
44, 649 S.F.
1.03 Ac.
EX. V
23,
FI
20.3'
COR C I I I
BENCHMARK 127'
TOP FND I s
EL -141.43 1 I
EXIST. FND.
COR A 43 8'
137.50
TANK IN:
135.95
o�PP��N
135.57
_
k 1' �
ROWU
o r
��o
EX. D -BOX
U /e�
sidb. 40052
39.0
Dogma
q
L = 8.9
o,�9FGISTER�� ���4
EX.
1500 GAL.
�v�vea
SEPTI
C TANK 4
�1
COR C I I I
BENCHMARK 127'
TOP FND I s
EL -141.43 1 I
EXIST. FND.
COR A 43 8'
�. �..\,.�RvICW
ELEVATIONS TAKEN AT TOP OF PIPE
TOP OF FOUNDATION: SEE PLAN
PIPE ® DWELLING:
137.50
TANK IN:
135.95
o�PP��N
135.57
D -BOX IN:
LOT 4
ROWU
0�
END PIPE - A:
U /e�
sidb. 40052
39.0
U �w)
q
L = 8.9
o,�9FGISTER�� ���4
-'Iw 37.4' old
sf� {
�v�vea
rx 0+N/fie~��
�1
116.45' � <f;
L-51.98'
�. �..\,.�RvICW
ELEVATIONS TAKEN AT TOP OF PIPE
TOP OF FOUNDATION: SEE PLAN
PIPE ® DWELLING:
137.50
TANK IN:
135.95
TANK OUT:
135.57
D -BOX IN:
135.39
D -BOX OUT:
135.24 (ALL)
END PIPE - A:
134.88
END PIPE - B:
134.90
END PIPE - C:
134.81
DRIVE
SWING TIES
COMPONENT
COR A
COR B
SEPTIC TANK
34'
58'
D -BOX
43'
50'
END PIPE: C
41'
31'
END PIPE: D
84'
34'
END PIPE: E
95'
56'
NOTE: THERE ARE NO WELLS OR
WATERCOURSES WITHIN 150' OF
THE SEPTIC SYSTEM
ASSESSORS MAP 105A LOT 003b
(CENTER)
(CENTER)
LOCI
N. T.
AS—BUILT SEWAGE DISPOSAL SYSTEM PLAN
LOT 5 BROOKVIEW DRIVE
NORTH ANDOVER, MASS.
PREPARED FOR
BROOKVIEW COUNTRY HOMES
P.O. BOX 531
NORTH ANDOVER, MASSACHUSETTS
I,JAR HIONDA & ASSOC., I - .P.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE. SUITE I
STONEHAM, MA. 02180
(617) 438-6121 DATE: 7/6/98.,.
SCALE: 1 "=20' REV. 10/27/97
REV. 9/10/98
REV. 10/29/98
X27.41'
N/F
LOT 6
4
roe, ai 43,114
0.99
44,649 S.F.
1.03 Ac.
EX. V NT
6 8'
23" E
EX. D—BOX
EX.. 1500 GAL
EX. 3 X 53 TRENCHES SEPTIC TANK
` 55.9' _ N TOP FND EL=141.43'
39.0'
S0411'22"W
OKVIEW
N04°11'22"E
. /..z-- 116.4
243.86'
DRIVE
243.86'
ELEVATIONS TAKEN AT TOP OF PIPE
TOP OF FOUNDATION: SEE PLAN
PIPE 0 DWELLING: 37-.50
TANK IN:
13 5, jr
TANK OUT:
135.57
D—BOX IN:
135.39
D—BOX OUT:
135.24 (ALL)
END PIPE — A:
134.88
END PIPE — B:
134.90
END PIPE — C:
134.81
AS -BUILT SEWAGE DISPOSAL
SYSTEM PLAN
LOT 5 BROOKVIEW DRIVE
NORTH ANDOVER, MASS.
PREPARED FOR
BROOKVIEW COUNTRY HOMES
P.O. BOX 531
NORTH ANDOVER, MASSACHUSETTS
EXIST. FND.
A. I~` 43.8'
r
_ L:=6090
R==125, 00
R:--=175 -�6,
L_S5.
SWING TIES
EX. VENT
EX. 3'
23.5'
F �~ `��
s _�
20.3'
7 C T.F. �C -_ .
ELEV.=133.
EX. 1500 GAL.
SEPTIC TANK
r� r7
N
46.5'
�L=8.92'
COMPONENT
COR A
COR B
SEPTIC TANK
54'
tis'
D --BOX
43'
50'
END PIPE: C
41.
51'
END PIPE: D
a4`
3c{'
END PIPE: E
q5,
m•
T.FND
ELEV.
(CENTER)
(CENTER)
MARCHIONDA & ASSOC., L.P.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE., SUITE I
STONEHAM, MA. 02180
(617) 438-6121
REV: 7/6/98 9�10%q8
SCALE: 1=30' DATE: 10/27/97
M & A FILE No.: 351 — 22
N/F 4
LOT 6 f 43,114
0.99
18
EX. VENT
_ EX. 3'
_--�---r- 23.5' D_ —
5
F
44,649 S. F.
_
�
1.03 Ac. 20.3'
C T.F. �C ~
ELEV. =133.
EX. V NT
23'--�---
68 EX. 1500 GAL.
E — — — — - ^ SEPTIC TALK
EX. D -BOX M
X. 1500 GAL.
EX, 3' X 53' TRENCHES SEPTIC TANK
------ 46.5'
D C
aCP_
55. 9'
TOP FND EL=141.43'
T. FND
$ A ' as.sELEV.
EXIST. FND.
127,41'
116.45'
SO4°1'I'' ?"N
DKVIEW DRIVE
N04"11'22"E 243.86'
ELEVATIONS TAKEN AT TOP OF PIPE
TOP OF FOUNDATION: SEE PLAN
PIPE ® DWELLING: 13}50
TANK IN: 1"3 5%
TANK OUT: 135.57
D -BOX IN: 135.39
D -BOX OUT: 135.24 (ALL)
END PIPE - A: 134.88
END PIPE - B: 134.90
END PIPE - C: 134.81
AS -BUILT SEWAGE DISPOSAL
SYSTEM PLAN
LOT 5 BROOKVIEW DRIVE
NORTH ANDOVER, MASS,
PREPARED FOR
BROOKVIEW COUNTRY HOMES
P.O. BOX 531
NORTH ANDOVER, MASSACHUSETTS
39.0'
L=51.98' ---3.
R
R-17 5
l _8E, . 1_C•
SWING TIES
COMPONENT
COR A
COR B
SEPTIC TANK
54'
6s'
D -BOX
43'
y01
END PIPE: C
41'
51
END PIPE: D
e4'
34'
END PIPE: El
q5'
(CENTER)
(CENTER)
MARCHIONDA & ASSOC., L.P.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE., SUITE I
STONEHAM, MA. 02180
(617) 438-6121
REV: 7/6/98 9�1o�g8
SCALE: 1=30' DATE: 10/27/97
M & A FILE No.: 351 - 22
)Vvrq OF t+!®R'I'H-,�:�
F.,a��/y ER%�
a:0."PO-) or x _I'l
ate.' `-_ .-7
d
Or,T 2 0 1.998
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned P(7—e
herebythat the Sewage Disposal System ()() constructed; ( ) repaired;
by k' Ser P X1).
�
located at 1 gee 0 6/1 t lJ pel do
was installed in conformance with the North Andover Board of Health approved plan, System
Design Permit # Z Z dated / I r' AF % , with an approved design flow of d
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.
Bed inspection date: ld/o / g i /G
Inspector
Final inspection date:
00//.S-%gtY
Installer:LT4 /4�, ^ Lic. #:
Design Engineer:
Inspector
Date: .rd /d I, I Lf
Date: 1014e