HomeMy WebLinkAboutMiscellaneous - 79 ROCKY BROOK ROAD 4/30/20184: 1
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ONSTRUCTIpN�_APPROV_k.'. ;
HAS,PLAN REVIEW FEE .DEEN PAID? YES NO
PLAN APPROVAL: DATE / �1/ J ¢ A. 4 --
APP. BY_
DESIGNER: 056001& J PLAN DA'rE:_6��570�-
CONDITIONS
WATER SUPPLY:
WELL PERMIT
WELL TESTS:
COMMENTS:
W� WELL
_ DRILLER
CHEMICAL DAIE APPRUVED
BAC E-E3I�AI UA I E
BACTERIA II DATE APPROVED
FORM U APPROVAL: / / APPROVAL 1.0 ISSUE E5 NO
DATE ISSUED e-�7l �CJ BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES
NO
YES
NU
YES
NO
YES
NU
YES
NO
DATE•
DY'
Commonwealth of Massachusetts RECEIVED
City/Town of MAY 1 1 2015
Sy$tem Pumping. Record. TOWN OF NORTH ANDOVER
FOrS 4 HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may 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 house, Left/ Right rear of hous , Le / righ( of Nous Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Un e
cityrrown
State Zip Code
2. System Owner.
Name'
Address (if different from location)
Citylrown ' State Zip Code
Telephone Number
-----------J
B. Pumping
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date 2. Quantity Pumped: Gallons y
Cesspool(s) ® eppUc Tank
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes 91N0If yes, was it cleaned? ❑ Yes ❑ Na
'5. Condition of
6. System Pumped By:
Neil. Bateson
Name i
Bateson Enterprises Inc
Company
7. LocationMdWe contents were disposed:
S. Lowell Waste M
F5821
Vehicle License Number
Date
t5form4.doc 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusettseiv ise
City/Town of
System Pumping Record
�� ri X013
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 house, Left / Right rear of house. 1�e9 h Nebo house eft /
Right side of building, Left / Right front of building, Left / Right rear of building, Under dec
Address
City/Town State Zip Code
2. System Owner.
Name
Address (if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua Pumped: 'Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditionf i;yst etn-�
6. System Pumped By:
Neil, Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7jSign
ere contents were disposed:
S. Lowell Waste Water
Haule Date
t5fonn4.doc• 06103 System Pumping Record • Page 1 of 1
`-3594
' NORTM "R.� 1 J� l .
3:
f - F
Town of North Andover
HEALTH DEPARTMENT
,S$ACMUStt .
CHECK #:1117
%1 DATE: /f/�
LOCATION:/1�
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:
Q -'Septic Testing
, �>
$w� 1
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
1
❑
Septic Disposal Works.Installers (DWI)
$
i
❑
Title 5 Inspector
$
❑
Title 5 Report
$ %
❑ Other. (Indicate) $
n
Health Agent Initials
White -Applicant Yellow - Health , Pink - Treasurer
i eWr,j ,OE NOR-FId ANDOVER
�"fificev CO��l��Ui�i TY DE`�E! QPP�ENT �,NDSERVICES
HEALTH DEPARTMENT p
16000ST PEE i ; 3ti L;! NG 2GSU-1TE9-36 •� . A<
NOR HAhrU:ER. VAS:^iCHUSE-T_jS 0I845 43SCmust"
4gs
��Ut)i!C Fic3lis'i I �Ii i�;i0t
APPLICATION FOR SOIL TESTS
81688.9540 Phone
9-78.688.8476 FAX
healthdept(clpIncfnoi'handover.com
v\,;�,, towr,,.of northa!idover. cor'n
DATE: I rl Nov"o OR MAP& PARCEL: 21 D q L0 � 30
LOCATION OF SOIL TESTS:
OWNER: TOWA cl g /� Contact #.
APPLICANT: Lam. as abD&Z Contact #
ADDRESS
ENGINEER: V• V7 i . Contact #.?0�` I� �P b
CERTIFIED SOIL EVALUATOR: IV42"I, aah-j
Intended Use of Land: Residential Subdivision !ngl Ho Commercial
IsThis: Repair Testing: V Undeveloped Lot Testing: Upgrade for Addition:
In the Lake Cochichewick Watershed? Yes No V
THE FOLLOWING MUST BE INCLUDED WITH THISFORM
Proof of land ownership (Ta( bill, or letter from owner permitting test)
➢ 8.5_x 11=Plot plan & Location of Testing (please i ndicatetest pit sites on the plan)
➢ Fee of $425.00 per lot for new construction. This coversthe minimum two deep holes and
two percolation tests required for each disposal area. Feeof $360.00 per lot for repairs or upgrades.
GENERAL INFORMATION
➢ Only Certified Soil Evaluators may perform deep hole inspections.
➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
➢ At I east two deep hol es and two percol ati on tests are requi red for each septi c system disposal area
Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH
representative.
➢ Full payment will berequired for ail additional tests withi n two weeks of testi ng.
➢ Within45days oftesti ng, ascaied0an(no smailerthan 1-100�shaiIbesubmitted tothe Board ofHeaith
showi ng the I ocati on of al I tests (i nd udi ng aborted tests).
➢ Within 60 days of testing soil evaluation for ms shall be submitted.
PIDo Not Write Below This Line
N.A. Conservation Commission Approval Date.
Signature of Conservation Agent:
Date back to Health Department: (stamp in):
ti
I
i
,I
koC)
k�
00k
¢9 (P� wato k -boa
Lot 17 /60.00-,,
�-
16,
.61,919 SFS
c �
I, op Of Foundation
Elevation = 134.22' -
Al-
Q _ X20
4
0
�bI l
Lot 14A
I
o f �
17. -C
nln PU'�/a .Co se vaiionl E se I en I I I ---.-Mosquito Brook
I I I Conservation EGseme.
�II�II LII
Thomas E. Neve Associates, Inc.
447 Old Boston Road — U.S. Route 1
i opsfie/d, Mossochuset is 01983 887-8586
Engl'neers — Surveyors — Land Use Planners
r,r`T Commonwealth of Massachusetts
;t 1
_j "City/Town of NORTH ANDOVER, MASS
System Pumping Record
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
isnen
CHUSETj$-,
DEP has provided this form for use by local Boards of Health. The Syste Purfflfd'Mdjust
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
I .- '�2
Address
�• �i'lio �iy
City/Town
2. System Owner.:
B.
Name
Address (if different from location)
State
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Zip Code
City/Town Stat / fi
���C�Jo�—S3 Zip � de
Telephone Number
umping Kecord
1. Date of Pumping
�. Type of system: ❑
r
4.
❑ Other. (describe):
Date 2. Quantity Pumped:
Gallons
- Cesspool(s) kseptic Tank ❑ Tight Tank
Effluent Tee Filter present? ❑ Yes [] No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6.
7
61 ilj.1�13 0/.
System Pumped By:
'*AyWz&
Name f Vehicle License Number
Company
Location where contents were disposed:
rN.1919 '5� ?f -Oz) k 1-
ignature auler —
http://wmv.mass.jov/dep/ er/approvals/t5forms.htm#inspect
t5form4.doc• 06/03
Date
System Pumping Record • Page 1 of 1
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Town of North Andover
Health Department
Location: A!446
(Indicate Addrdrs, if Residenti
Check #:
�
Date:
!`! 1�4
or Name ofi Hess)
Type of Permit or License: (Circle)
__ ➢ . Animal
Dumpster
Food Service - Type:
Funeral Directors
➢
'Massage Establishment
$
°. ➢.
Massage Practice
$
V' ➢
Offal (Septic) Hauler
$
R, ➢
Recreational Camp
$
. ➢
SEPTIC PERMITS:
❑
Septic - Soil Testing
$
,
❑
Septic - Design Approval
$
❑
. Septic Disposal Works Construction (DWC) $.
M
Ll
Septic Disposal Works Installers (DWI)
$
➢
Sun tanning
- ➢
Swimming Pool
$
➢
Tobacco r
$
➢
TrashlSolidWaste Hauler` -
$
}
➢
Well Construction
$
A
➢
OTHER: (Indicate)Jr
Health Agent Initials
1
At.
White - Applicant';r. Yellow -Health Pink - Treasurer
R.J. INSPECTIONS, INC.
d � °
. 6-19-06
Town of North Andover $50.00 JUN 2 3 2006
TOWN OF NORTt•i .AN,',�`•<
Title V Fee for 79 Rocky Brook Rd. North Andovei MfA.PALTH DEPARrPJ,i_r-1
10810
v
Town of North Andover $50.00 JUN 2 3 2006
TOWN OF NORTt•i .AN,',�`•<
Title V Fee for 79 Rocky Brook Rd. North Andovei MfA.PALTH DEPARrPJ,i_r-1
10810
c ..
y
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTRCTTON
IEIVED
JUN 2 3 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
TITLES
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: %% f�p Iryc�kc
n � ot8
Owner's Name: c `
Owner's Address: 5>rr e
Date of Inspection: _ L —S— 06
Name of Inspector: lease print) �< t0/—ju%�!
Company Name:mc
.,- �nSp
Mailing Address: _t�i�� �¢�� Q5f,
Telephone Number: q7?-4,F1—.37V
CERTIFICATION STATEMENT ,
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
C nditionally Passes
Beds Further Evaluation by the Local Approving Authority
Fails
w
Inspector's Signature: Date:
- _ "
'�"�''.�.. .....— .. Date:
The system inspector shaiJ'submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of d6mpleting this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: `o_P%GO d
�P ,r �P2 MR oi6sys
Owner: au L j�d u s k
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 in ' ates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any fail 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
,r
indicating that the tank is less than 20 years old is available,-.,
ND explain:
Observation of sewage backup or b ak out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, se ed or uneven distribution box. System will pass inspection if (with
approval of Board of Health);
bkken pipe(s) are replaced
obstruction is removed
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:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7_ ko6k-
NGr 14 ffin40�LL Ak14 ofs-yh-
Owner; PQ .L kei! a ;
Date of Inspection; A A
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 5letermines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manne hich will protect public health, safety and the environment:
_ Cesspool or privy is withi 0 feet of a surface water
Cesspool or privy is wi in 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.
yam,
i
— The system has a septic tank and SqS dnd the SAS is within 50 feet of a private water supply well.
_ The system has a septic t•"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,,t`f the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 P40- d—k—�oa
Owner: PAwl- k�A M Y
k 0 P h A.Y, � k r
Date of Inspection: (o /l./nA
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes
chp of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
�_ y portion of the SAS, cesspool or privy is below high P P �'Y bh 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.
_ eAnY
y portion of a cesspool or privy is within 50 feet of a private water supply well, portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) 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.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in dition to the criteria above)
yes no
the system is with. 0 feet of a surface drinking water supply
—
the syst 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.
Page5of11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7'? nr IV— "r,,,,A ,,e.,
Owner: 9�►ki c+s �tA jSl<a
Date of Inspection: ( A4 /ej,6
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
p Board of Health
Wer r,any of the system components pumped out in the previous two weeks
Has the system received norma flows in the previous two week period ?
..Have large volumes of water been introduced to the system recentlyof this inspection or as part p coon ,
4z/_"7 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 p with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes o
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) [3 10 CMR 15.302(3)(b)]
Page 6of11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7?
Owner: <
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of7., K_drooms):
Number of current residents.
Does residence have a garbag grinder (yes or no):
Is laundry on a separate sewage system (yes or no): /l/' [if yes separate inspection required]
Laundry system inspected (ye or no): _
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage (gpd)): SL'2'
Sump pump (yes or no): �!f
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of desig>inggs,
s/persons ,etc.):
Grease trap prr n
Industrial waspresent (yes or no): —
Non -sanitary rged to the Title 5 system (yes or no): _
Water meter rvailable:
Last date of occupancy/use:
OTHER (describe):
Pumping Records GENERAL INFORMATION
Source of information: 4�,�tJf4z L,7
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping:
TY 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, dat m 1 d if known) and source
tri✓!= t.S �-je, /
Were sewage odors detected, when arriving at the site (yes or no):
,1f
OFFICIAL INSPECTION FORM – NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �tr , r
id(11(10- MA
Owner: �� r
Date of Inspection; LZV16— 4'
BUILDING SEWER (locate on site plan)
Depth below grade:. 3 '_
Materials of construction: cast iron _40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: _ (locate on site plan)
Depth below grade: ' y
Material of construction: —concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: %, X x
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: v28'
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: l°L p j/4 _�
Continents (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of,leakage, etc.):
/11-0 - �'-i z- "
GREASE TRAP: _(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass __polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum op of out
tee or baffle:
Distance from bottom scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
r P age % of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Bmok
/VszrTVl flyi.i`r A Glg�fS
Owner: �At'-L � ", , stn C ;
Date of inspection: (� /,E/.— 6
01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity:---- allons
apacity:allons
Design Flow: allons/day
Alarm present (yes no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Conunents (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Deptli 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.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or
Comments (note condition o mp chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: c- kmckkd
q /a'/S-
Owner: %a
Date of Inspection: _ 6/9
SOIL, ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
1pehing galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Continents (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
4/'%�1Ci6/GC� IJ
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 groundwate ' flow (yes or no):
Comments (note condi ion 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 condit of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc•):
Page 10 of 11 9
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:p&K t1�p �� d.
Owner: uu, ek
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
5.e e- A#,4 Cly -- d eo P � a �- P/,4 tV
I
Page 11 of 11 .
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
N AA b!k Y�
Owner: ELL
Date of Inspection: _ 61a ate_
SM
Slope
er
Check cellar
Sha ow wells
Estimated depth to ground water 6�t'et
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must ducribehow you established the high groundwater elevation:
-e'
IN
io
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17
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Jun 19 06 10:53a
Summary Record Card generated on 6/1912006 10:06:47 AM by Lisa Warren
_ Town of North Andover
Tax Map # 210-090.A-0050-0000.0
79 ROCKY BROOK ROAD
KOCHANSKI, PAUL & SHELLY
79 ROCKY BROOK ROAD
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type
Size Total 1.17 Acres
FY 2006
UB Mailing Index Active/lnact
Name/Address Type Loan Number
KOCHANSKI, PAUL & SHELLY Payor
79 ROCKY BROOK ROAD
NORTH ANDOVER, MA
01845
From
UB Account Maint. Active/Inactive
Account No Cycle Occupant Name
Bldg id. 18064.0 - 79 ROCKY BROOK ROAD Last Billing Date 4/10/2006
Active
3180093 03 Cycle 03
UB Services Maint.
Service Cod® Rate Charge Multiplier/Users
9'18
MISCFEE ADMIN FEE 1 1 11
WTR WATER 01 ALL METER SIZE 37.29 /1
UB. Meter Maintenance
Serial No
Status
Location
13240216
a Active
ERT HH
Date
Reading
Code
3/20/2006
258
a Actual
1/3/2006
247
a Actual
9/15/2005
227
a Actual
Trouble
Code:03
17
6/14/2005
125
a Actual
3/25/2005
100
a Actual
12/15/2004
82
a Actual
9/17/2004
68
a Actual
6/14/2004
32
a Actual
4/23/2004
15
c Correction
C/PO+ERT
15=15
12/23/2003
840
n New Meter
Brand
Type Size
METE METE
w Water 1 1
Consumption
Posted Date
11
4/17/2006
20
1/17/2006
102
10/14/2005
25
7/15/2005
18
4/5/2005
14
1/1412005
36
10/8/2004
17
7/30/2004
15
5/17/2004
0
12/23/2003
P.1
Page 1
1 Residential
Until
YTD Cons
0
variance
-20%
-83%
255%
71%
14%
-58%
16%
166%
0%
0%
LETTER OF'rR.ANSNITr'rA1.,
North And(iver Health Department
400 Osgood Street
North Andover, )NIA 01845
978.688.9540 - Phone
978.68 8.8476 - Fax
healthdept-a::townofnoi-thandover.eom - E-mail
wwiv.townofuorthandover.com - Website
N0RT�y
-1N
k1r—
40C...4 tW.CNR^reD ',.t1Page L ofSS�+e
TO:(�
DATE:
117 O�
c.L'
G
COMPANY:
FROM: Pamela DelleChiaie, Health Department Assistant
RE:
Phone:
Fax:
/ 41
We are sending you: OCopy of Letter OPlans OO r (fill in below)
These are transmitted as checked below:
0Appinued as Nn - v OFor Review quad comment y Muhnd copies for
O equesterl > OFor Your Use dish
MsRegubW Y OResuhnik copiesfor
CForApproW
appmal
REMARKS:
COPY TO:
COPY TO:
SIGNED:
COPY TO:
ACTIVITY REPORT
TIME
04/07/2006 13:11
NAME
HEALTH
FAX
9786888476
TEL
9786888476
SER.#
000B4J120960
NO.
DATE
TIME
FAX N0./NAME
DURATION
PAGE(S)
RESULT
COMMENT
#407
03128
10:29
89786836023
32
02
OK
TX ECM
#408
03128
12:16
816175578621
03:41
17
OK
TX ECM
#409
03128
12:27
89786836023
45
03
OK
TX ECM
#410
03128
12:52
817817291794
02:06
03
OK
TX ECM
#411
03128
13:28
819782820012
41
03
OK
TX ECM
#412
03128
15:46
89786851099
52
03
OK
TX ECM
03129
07:30
30
00
NG
RX
03129
07:37
19
01
OK
RX ECM
#413
03129
10:00
819783742315
04:02
14
OK
TX ECM
#414
03129
11:33
819782820012
37
03
OK
TX ECM
#415
03/29
12:19
819784588994
04:05
17
OK
TX ECM
03129
14:14
800 741 1503
19
01
OK
RX ECM
03129
14:17
19876823637
01:22
03
OK
RX ECM
#416
03/29
15:48
817813344330
26
02
OK
TX ECM
#417
03129
16:25
819786829064
24
02
OK
TX ECM
#418
03/30
08:30
819786497582
22
01
OK
TX ECM
#419
03130
11:12
819787940707
15
01
OK
TX ECM
#420
03130
11:51
89786888058
01:16
03
OK
TX ECM
03131
09:02
19786888058
01:20
03
OK
RX ECM
#421
03131
11:15
817819793994
14
01
OK
TX ECM
03/31
11:25
978 685 9611
52
03
OK
RX ECM
#422
03131
13:55
819782820012
43
04
OK
TX ECM
03131
14:31
19
00
NG
RX
03/31
14:33
978 258 2682
34
02
OK
RX ECM
#423
03131
15:13
19789757909
00
00
BUSY
TX
04103
08:32
30
00
NG
RX
04103
08:38
14
01
OK
RX ECM
04/03
09:44
9785218648
25
01
OK
RX ECM
04103
10:01
800 741 1503
16
01
OK
RX ECM
#424
04103
10:29
89782582682
21
01
OK
TX ECM
#425
04/03
12:15
817819793994
14
01
OK
TX ECM
#426
04103
12:31
819784096277
00
00
BUSY
TX
#427
04/03
12:43
819784096277
01:45
13
OK
TX ECM
#428
04103
15:15
817812459258
26
03
OK
TX ECM
04104
11:27
978 623 8374
02:19
02
NG
RX ECM
04104
11:39
978 623 8374
54
03
OK
RX ECM
0429
04/04
11:59
819784091269
01:20
04
OK
TX
04/04
13:09
978 688 9603
41
04
OK
RX ECM
04/05
08:41
2
16
01
OK
RX ECM
04105
13:00
9786497582
01:49
04
OK
RX ECM
04/05
15:37
19
02
OK
RX ECM
#431
04105
16:28
89786851099
00
00
BUSY
TX
04/06
09:39
9784636631
22
02
OK
RX ECM
04106
09:48
800 741 1503
14
01
OK
RX ECM
#432
04106
15:01
89788518547
30
02
OK
TX ECM
#434
04/07
10:56
819786641450
02:29
05
OK
TX
#433
04/07
10:59
819786641450
02:29
05
OK
TX
#435
04107
12:11
819786889544
05:01
06
OK
TX
#436
04107
12:23
89786825335
03:05
11
OK
TX ECM
BUSY: BUSY/NO RESPONSE
NG POOR LINE CONDITION / OUT OF MEMORY
CV COVERPAGE
POL POLLING
RET RETRIEVAL
PC PC -FAX
TRANSMISSION VERIFICATION REPORT
TIME
04/07/2006 13:10
NAME
HEALTH
FAX
9786888476
TEL
9786888476
SER.#
000W120960
DATE DIME
04/07 12:23
FAX NO./NAME
89786825335,
DURATION
00:03:05
PAGE{S}
11
RESULT
OK
MODE
STANDARD
ECM
4
.. '
COMIVIONWEALT-H OF MASSACHUSETTS
I -A. VV; V0TTrPTX7V %iL'L' OV nV P1ATZ7-TDrNXT?ufVAT*PAT AVVATDQ
SUBSURFACE- SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspector: (p ease print);._ , � ` t°
Company Name: 1 fU/C
Mailing Address:
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
asses
Conditi ally Passes
Ne ds urther E aluation by the Local Approving Authority
F is
e,;.. Inspec:tor's Signature: Date: �--
s The system inspector shallipleting
mit a copy of this inspection report to Approving Authority (Board of Health or
DEP) within 30 days of co this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
i tete ssy,�}{'vpi4M9!
`'Pae 2. of 11.11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS " -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION. (continued)
Property Address:
Owner .
Date of Inspeo�on:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
We f I have not found any information which indicates that any of the failure. criteria described in 310 CMR
16.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments: (y3'
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:.
l
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
t explain t•
t
' The septic tank is,metal. and over 20 years old*' or the septic tank (whether metal or not) is structurally
s unsound, exhibits substantial infiltration or exfi'ltration 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
i -obstructedpipes) or due to a broken, settle'or uneven distribution box. System will pass inspection if'(with .
oardo
approvalof�B °fH'4
ealth). .> _ ;� �. .a.
brokeu,pipe(s) are replaced'
obstruction is removed
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`reriioved '
ND explain:
2
��j,°; Y"i y3i i}y'tF}Yf�'�l$,yt�����.'Lji4t. •.. .�
w Page 3. of 11 .
OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 'A
CERTIFICATION (continued)
Property Address: �' r
1144
Owner:
Date' of Inspecti6n: ,
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 atmanner^wh ich will protect public healthx 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
x 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
r, system,is functioning in a manner that protects the public Health, safety and environment:
The system has a septic tank and soil absorption system:(SA.S),and the SAS is with in 100 feet of a
surface water supply or tributaryto a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone i 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
4
* *This system passes if the well water analysis; performed at a DEP certified laboratory, for coliform
bacteria andvolatile organic compounds indicates that the well is free from,pollution from that`facility and
° the'presence of:ai moiiia •nitrogen aril nitrate nitrogen is equal to &46ss tha65 ppm, providedAhat no,other
failure criteria are triggered. A copy of the analysis must be attached to this form:
3. Other:
3
- -
- X
3
.:.J•V.r. .._. ,..r .,.�_..e... �w�a;,-•.�.'1�' a_x w ^v'-ew.v�--�".yY �"44M-1�--W+'. L..v...0-f f F♦y. k �w .ala-W.labh+i,,:yw+,nLwWk'-"iFRL'�,CMkf:+"�'T:�WW'a€"+�YMM W^W'M�'.P.i+1r+N"V'°.r,..�y�s4in'a.—r'
^F�Mlil
Page 4 of .11
OFFICIAL INSPECTION FORM — NOT -FOR VOLUNTARY ASSESSMENTS
" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
,
Y
Property Address Q %'�
^�f �
Ownery
' Date of Inspec19bn: -.
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 pondingof effluent to the surface of the ground or surface waters due to an overloaded or
r clogged SAS -or cesspool
I Static liquid level in the distribution box above outlet invert due to an overloaded or clogged`SAS or.
/'cesspool
_ V j-iquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow
_ V Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
Any the S,
SA is below high
portion of cesspool or privy ground water elevation.
- _ 7ZAny portion of cesspool or privy is within 10.0 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. -
.'
' Anyportion of a cesspool or n is within "50 feet of a private water supply well.
Pprivy P PP Y
_ _4e. Any portion of a cesspool orprivy.is less'than 100'feet but greater than 5D.feet from.a>private water
` ;
`. "'supply well with no acceptable water.quality'analysis. [This system, passes if the.'well water analysis,
performed ata DEP certified laboratory, for coliform bacteria and volatile organic.compoma&
indicates that the well is free from pollution from that facility and the presence of ammonia,
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
f 0 (Yes/No) 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 contacts the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems
Po be considered a large system'the system must serve a fac litywith a design flew of 10,000 gpd .to 15,000
gPd•
You must indicate either "yes" or "no" to.each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
. _ the, system is within 200 feet of a tributary to a. surface drinking .water supply -
_ thes "stem is located in a nitr WPA) or a mapped'1;;
4 y ,nitrogen sensitive area (Interim Wellhead Protection Area-. I
Zone Il of a public water supply well
µ.
.
s . If you have answered "yes" to any question m 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 systerri 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.
4
0
Page 5 of 11
N.
OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
Yes No
Pumping information. was,provided by the owner, occupant, or 136aid of Health
Were any of the system compoiniefits pumped out in the previous o w -eks?."
_Z11 Has the system received normal flows in the previous two week period ?
ZHave 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 ?
r, signs of break, out,)
Was the siwinspecied fb
Were, all sy§tem'components'excludihg the,S_ASjoc ated 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 9
Was the facility owner (and occupants if different from owner) provided With information on the proper
maintenance of subsurface sewage disposal systems ? r.
The size' and'16cation of the Sbil'AbsorptiowSysteni'(SAS) on the site has been deteirmmedbased on:
J
Yes no
Existing information. For example, a plan at the Board of Health.
1,/ Determined in the field (ifanyof the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15,302(3)(b)]
4 Page 6 of 11
6
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x.# of bedrooms):
Number of current residents:
Does have 7o
residence a garbage grinder (yes or no):Ke elcomco-�
Is laundry on a separate sewage system (yes or no): [if yes separate inspection'iequired]
laundry sy, (yes gr no):',,':
stem ih9peciedA
? . t , i
Seasonal use: s Of no):
ye
Water meter readings, if available (last 2 ye&s usage (gpd)):
Sump pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL'..
Type of establishment:
Design flow (based on 31.0 CMR 15.203): gpd,.
Basis of desi gn flow (seats pers0 ns/s4ft,etc.):,
Gtease trap present (yts'or no).'
industrial waste o ing tank present (yes or no):.
Non -sanitary waste dischaiged:to the Title 5 system : (yes ornb),
Water meter readings, if available:
.Last date, of mcupancy/use,
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information:rn
s r PU
Was system pumped as part f the *inspection (es or no):
If yes, volume - How determined?
pumped.�—%gallons was quantity pumped
Reason for OA) pumping
TYPY/OF SYSTEM
Septic tank, distribution box, soil absmptim sysftm
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
Odier (describe):
,-Af 11 nents, date installed(ifknown) and source of information:
pproximateage 9. a com o
Were sewage odors detected when arriving at the site (yes or no):/VO
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction: _cast iron40. PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of.Jeakage, etc.):
A ..:+
i /
SEPTIC TANK: !/(locate on site plan)
Depth below grade:
Material of construction:oncrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed .bv a Certificate of Compliance (ves or no): (attach a copv of
Distance from bottom of scum to bottomof-outlet tee or baffle: �L_:
How were dimensions determined: 70 ale %J GC j P .t--(-
Comments (on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels
as re�ated�tewutlet invert, evidence f leaks , etc.: ¢
GREASE TRAP (locate on site plan) r +
Depth below grade: _
Material of constriction: _concrete metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels;
;as related,to outlet invert, evidence,of leakage, etc.):
C
7
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• ;.-Page 9 of 11
If SAS not located explain why:
? t
leaching pits, number
leaching chambers, number:
aching galleries, number: -- % `
aching trenches, number, length: f `Cty C'& S 20, h
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology; .
R
Comments (note condition of soil', signs of hydraulic: failure, leyel.of ponding, damp soil, condition of vegetation,
etc. • , / / --�
U- 1" i C.� ct f L 'u �^-e ,'CG '�o.-/� 1 G# tom? ):, . J '/ �' ALU Cell
h
yy44 4
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 or i
Comments".(jote condttion4of spil s'
j.
PRIVY: (locate on site plan)
failure, level„of ponding; congitioin off vegetation, etc)
9
L
Page 10 of 11
10
�e I
.Inf.
'age I I of 1 I
.e
OFFICIAL; INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT C z
t Date
f In'spego&: L/
SITE EXAM
Slope
•
"
Check cellar
Shallow wells
4,s,timated depth to grount water feet
0
OFFICIAL; INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT C z
t Date
f In'spego&: L/
SITE EXAM
Slope
•
Surface water
Check cellar
Shallow wells
4,s,timated depth to grount water feet
Please indicate (check) all methods. use't"o determine the high groundwater elevation:
1Obtained
from system design plans on record - If checked, date of design plan reviewed:���
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked,with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
-7-7-7—
You 'mus descr e how you establi' hed the high ground water elevation
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Applicant
NA
Site.Location e
Town of North Andover, Massachusetts Form No..3
BOARD OF HEALTH —f-cz—�
19�
DISPOSAL WORKS CONSTRUCTION PERMIT
'<5;� v/
L
TE
Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
h AIRMAN, BOARD OF HEALTH
LJ �
Fee D.W.C. No. _ 77�_
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Phone
LOCATION: Assessor's Map Number Parcel
Subdivision Lot s ) Z-0
Street LIg e, St. Number
Use Only************************
RECON24END ONS OF TOWN AGENTS:
<�z/,,
,,,,,,,,j
nsery ion Administrator
Comments
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Anuroved / /
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
pORTN
o �
9
s�CHUSE
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
7E-6 / 19. 94
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
k t y -aK
Applicant �P-L--if) (D5000n; J2l-�,5947-y T,P Test No.
Site Location 2, /6 � - y`�•eoaie --Tb
Reference Plans and Specs. 41CCL) CiyG���.vn Ci✓G
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 0
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DATE_' 1 X. :-2,?,
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE_PERMIT # DATE RECEIVED
APPLICANT'oe ��zTy 71 AS
�GK/ �'SESSOR'S MAP_ 90
ADDRESS 770 5f A1./- PARCEL #
LOT #
STREET
ENGINEER %l% C/U< EiVr - S,�PVtC
ADDRESS 33 Aj . /P
PLAN DATE c9, / ✓/ 1?¢ REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED _
.
043,'
ND 7-6 fd/�i 5,76/4:�—r' 7-0 —15 C
7 -C -In P2
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���/r�v,�✓i , Fav ;
NEW ENGLAND ENGINEERING SERVICES
INC
Y M1,
I !nr
April 5, 1994
P -
North Andover Board of Health
120 Main Street
North Andover, MA 01845
Atten: Sandra Starr
Dear Sandra:
Enclosed is a revised design for Lot No. 16 Rocky Brook Road.
This design corrects the deficiencies outlined in your letter
to me dated March 29, 1994.
The only item remaining is to do some additional soil testing
in the system area, which I would like to do on the
thirteenth when you are out at the site.
Yours truly,
0VcOd
Benj'min C. 0Jr.
x
Enclosure
33 WALKER RD. - SUITE 22'- NORTH ANDOVER, MA 01845 - (508) 686-1768
ER ENVIRONMENTAL.
lvrl__M�
ENGINEERING.
969 WASHINGTON STREET
BRAINTREE, MA 0218.4.
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
CERTIFICATION
Owners Name: az- er _/cIc- A16,V&rYN1A Je— Address of Owner (if different):
P rope rtyAddress:
Aod va, /y Company Name:
.Date of Inspection:Mailing Address:
Name of Inspector: 61AANI A/. _D�017416
I am a DEP approved system inspector pursuant Telephone Number:
to Section 15.340 of Title 5 (310 CMR 15.000)
CERTIFICATION STATEMENT -
F -1 Voluntary Assessment (Not Reported)
Name
I certify that I have.personally inspected the sewage disposalsystem at this address and that the informabon reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance. of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By The Local Approving Authority
Fails
Inspector's Signature: e.:
Date: by i
The system inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing
this inspection. If,the system is ra'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 Department'of Environmental Protection. The original should be sent to
the system owner and copies sent to the buyer, if applicable, and the approving authority..
INSPECTION SUMMARY:
'. Check A, B, C, or D
TEM PASSES:
kr I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CMR 15.303. 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe bas'Is of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or Operator has provided the -system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved,by the Board of Health.
1 of 10
Property Address:
Owner: A
Date of Inspection:
IGER. ENVIRONMENTAL Ttrc
ENGINEERING
969 WASHINGTON' STREET.
BRAINTREE, MA02184
617.-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
a
B] SYSTEM CONDITIONALLY PASSES`"(continued) -..
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled, or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health): Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
i
The system required 'pumping more than four 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
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,the public health, safety and the environment.
1) ;SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING
IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 saltmarsh
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, -IF APP
ROP
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE"PUBLIC HEALTH
AND SAFETY AND THE ENVIRONMENT: -
The system. has aseptic 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. ;
r•The system has a septic tankand: "soil absorption system and the SAS is within a Zone 1 of a public water
;a supply well. = , , ..
The system has a septic tank.and soil absorption`§ystem and the SAS is within 50 feet of a private water
r; supply well.
is ,ti.•
The 'system has a septic tank and soil absorption -system and the SAS is less than 100 feet but 50 feet or more
from'a private water supply well, unless a well waterIanalysis for coliform bacteria and volatile or com-
pounds indicates that the well is free from pollution from that facility.and the presence of ammonia nitrogen
and nitrate nitrogen is equal to or less than 5 ppm:
Method used to determine distance: -- r ' ! �` (approximation not valid).
3) OTHER:
nh
2 of 10
, r .. gF.'1T�,.. .h.`,�:Y�R�+�7fTM�i'VW(�.YFi�/O�Ya,��Y'*l�•',�,r,i:rr�r�' �x;1 ti iM#,r�:,��' ..,. .., ,., �,.. r,kyF;�Pd6g7�iifm`7Pv�"��p"�t""�`ff'�:yi"�,.-5+'15,;§biarti�i �i+t•"+'P�7!%�s,:^++p'tif'�ri�'"w'�r,«,�ri'4'nri .-Siy n'..7.r,
TIGER ENVIRONMENTAL
a, ENGINEERING,
969 WASHINGTON STREET
BRAINTREE; MA 02184
r 617-849-0088
w:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Rey &ioe e 121 ; A.I. fT "065A > qA
Owner: /16V57-
Date
16VS7'Date of Inspection:
F
D] -SYSTEM FAILS:
You must indicate either''.Yes orNo as-to--each-of the -following': - -
I have determined that the system violates one or more of. the following failure criteria as defined in 310 CMR 15.303.
The basis for this determination is identified below. The Board of Health should be contacted to determine what will
be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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. ` p"
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If -the well has been analyzed,to.be acceptable,. attach copy ...... ,
of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and `nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facilitywith a design flow of 10,000 gpd or greater (Large System) and the system is a significant
threat to public health and safety and the environment because one or more of the following conditions exist:
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 suface drinking water supply.
The system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA).or a mapped
Zone 11 of a public water supply well).
The owner or operator of any such system shall bring the system and facility into full" compliance with the groundwater treatment
program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
3 of 10
{TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA 02.184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �� kocvw 62mx A /V— 11QZ. Am
Owner: 57-YklA1c'., ,
Date of Inspection:
,W"
r.
Check if the following have been done:
: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been
receiving normal flow rates during that period. Large volumes of water have nbt been introduced into the
system recently or'as part of this inspection.
As built plans have been.obtained and examined. Note if they are not available with N/A. .
The facility or dwelling was inspected, for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout:
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for
6fscum.*!
X _ , th
of slud ede
condition of baffles or tees, material of construction dimensions, depth of liquid, depth " g p
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on thero er
p P
maintenance of Sub -Surface Disposal System.
x•; . Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part Cis at issue, approximation of distance is
unacceptable) [15:302(3)(b)]
y. 4 o 10
e }M.
} "yMr�' ro� ��RW:S� �NhrY.;r�i�� � ��' ki, fi• "`�?-Plkt .ti
DIGER ENVIRONMENTAL.*;,.,,,,,
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 12c t 122OG /�/J •, i(/.
Owner:hgj6 =-' /V /ANe--
Date of Inspection: //— P8
FLOW CONDITIONS
RESIDENTIAL:
r Design flow: 014(&
Number of bedrooms:
Number of current residents:
Garbage grinder: (yes or no)
Laundry connected to system: yes or no)- .�97 —40 %17 Zp j 9 7 S -O
Seasonal use: (yes or no) 0 j
Water meter readings, if available [last two (2) year usage (gpd)]: Z/?7 319i 25 ah 4j /0
Sump Pump (yes or no): /Jo
Last date of occupancy: C.crNT�
COMMERCIAL/INDUSTRIAL:
Type of establishment
Design flow: gallons/day .
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Nori-sanitary waste discharged to the Title 5 system: (yes or no)
~` Water meter readings; if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informatio T
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping: "'—
TYPE OF SYSTEM:
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
No Shared system,(yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other (explain)
AGE of all components, date installed.(if known) and source of i
Sewage odors detected when arriving at the site: (yes or no). II/G
5 of 10
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I
DIGER ENVIRONMENTAL u� a
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property AddIress: 7 �' 'a� Al 4Qe� , /A
Owner: /4'+/6w 5?'`Ii IIAA �
Date of Inspection: i --1/- 9 -7- 98
BUILDING SEWER: (Locate on site plan)
Depth below grade:
Material of construction _ °cast" irort - -40 PVC= other (explain)
Distance from privatelwater supply well or suction line:
Diameter:
Comments: (condition of joints, venting, evidence of leakage, etc.) _
SEPTIC TANK:Ems. �� (Locate on site plan)
Depth below, grade:
Material of construction: concrete metal Fiberglass Polyethylene other (explain)
If tank is metal, list a e ;G. Is age confirmed by Certifi ate of Compliance? (yes/no)
Dimensions: x! X � p l 4570 3 MtS�
Sludge depth: /VOV r' .
Distance from top of sludge to bottom o . utlet to___.p trafffe: A
Scum thickness: Mw
Distance from top of scum to top o outf�let tee-er+af le- AIA y
Distance from bottom of scum to bottom of�utlet to or -baffle:' AVA
How dimensions were determined: NI&f /n 5,1ZE AUL 777,VAe .
Comments:.
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Na 104)1r,0tW6- A7— 72 iS 77�E ' A6771 IAIL-t7 -- A7b o UTZe-r-
-7;4Ae- fi�VZJ IXS STS-c/G7VK4 .Sot/�v/ 607# NO 6VrPQf/45� 0)�'
GREASE TRAP: No (Locate on site plan)
Depth below grade:
Material of construction concrete metal Fiberglass Polyethylene other (explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: F
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments: :
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
6 of 10
TIGER ENVIRONMENTAL 1:.<:7_1' i
A"
ENGINEERING,,
969, WASHNGTON STREET
BR'AINT
,EE MA,02184
617=849-0088 46 -0088.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: 4�-11-
TIGHT OR HOLDING TANK:. A/O (Tank must be pumped prior to, or at time, of inspection)
(Locate on site plan)
Depth below grade:
Material of construction: concrete metal Fiberglass Polyethylene other (explain)'
.F. Dimensions
4
-Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order yes; no
Date of
previous pumping:.,
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: la 6017-4
(Locate on site plan)
Depth of liquid level above outlet invert:
Comments: (note if leveland distribution is equal ;eviden6, of solids, carry over, evidence of leaka etinto, orout of box etc.)
PUMP CHAMBER: AIQ
(Lo6ate on site plan)
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments: (note condition -of pump chamber, condition of pumps and appurtenances, etc.)
7 of 10
TIGER ENVIRONMENTAL
ENGINEERING,,.,..,
969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: � A-4amwe 12A fVo nl % AM
Owner: I,vSTy�v/A '
Date of Inspection:
`r
SOIL ABSORPTION SYSTEM (SAS): �S
(Locate onsite plan, if, pobsible;,excavation,not required; but"may be app"roximated by non -intrusive methods)
If not determined to be present, explain:
Type:
Leaching pits, number: /0674. Its !,6U1 Lr Nv&-
Leaching chambers, number: J06 #- $'U x-16
Leaching galleries, number: �4s E- /vel. V
Leaching trenches, number, length: 2772 WiZek 32 L0A/6 /1/
Leaching fields, number, dimensions: �
Overflow cesspool, number:
Alternative system: Zoj /99�
Name of Technology:
Comments: (note condition -.6f soil, siqns of.hvdraulic failure, level of Dondina..condition of veaetation_ Ptr.1
CESSPOOLS: yo
(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: T p r
Indication of groundwater:
Inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: ' `ti•
(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.) .
8 of 10
=TIGER. L
. ENVIRONMENTA*,,".
W,
�ENGINEERiNGvas I,,,,,,,,,,,,%--.
969 WASHINGTON'STREET
BRAINTREE, MA 02184
617-8491-0088
SI*URFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION (continued)
Property Ad dress: — 14 r-ag J—Y&-Z X4-) /v -
Owner: AW,-US7-YA) i A R—' 7
Date of Inspection: 7-2-Y8
SKETCH OFSEWAGt ll§ii SALL
Include ties to at least two permanent references, landmarks.or benchmarks
Locate all wells within 1 00':(Locate where public water supply comes into house)
•.
. .
. . . . . . . . . . . . .
F- LE VATED
. . . . .. . . . .
As
. . . .
48 , .
.
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.�-.-�'.
4 B�t�
•A&_
. . .
. . . . .
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. . . . . ... . .-Y
"j A . . . . . .
. . .
. . . . .
. .
. . .. . . . . . . .
. . . . .
• 17,1
. .:SAS . . .
AP -EA .
. . .
. . . . . . . . . . . .
. . . . .
. . . . . . . . . .
. . . . .
. . . . . . . . . . . . .
. . . .
. . . . . . . . . .
. . . . . .
. . . . . . . . . .. . . .
... . .
. . . .
.
. . . .
. . . . . . . . . . . . .
. . . . .. . . . . . . .
. . . . . . . . . .
. ... . . . . . . .
9 of 10
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4
--TIGER ENVIRONMENTAL .
ENGINEERING
' 969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:PART C
SYSTEM INFORMATION (continued)
2 - Property Address: N.
w Owner: Ay6v,57YNiA
Date of Inspection:
6-0-
_P
-0 98 -98
DEPTH TO GROUNDWATER:
Depth.to'groundwater..., feet• : &aqV;
Please indicate all the methods used to determine High Groundwater Elevation;
Obtained from Design Plans on record
X Observation of Site (Abutting property, observation hole, basement sump, etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA maps
Check pumping records
rz
Check local'excavators, installers
Use USGS,,Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed).,
P
s
480K f�-1 4i/6 -) No
The intent of 310 CMR 15.302 is to provide reasonable guidelines for the inspection of existing systems in as non -intrusive a manner as
is possible to avoid damage, to the system and any unnecessary disturbance of the surrounding soil area which is related to the
treatment process. The inspection is not designed to provide information to demonstrate that the system will adequately serve the use
to be placed upon it by the new owner. The inspection criteria are intended to allow for timely inspection to avoid undue delay in the
transfer of property.
I understand that this report does not constitute a warranty or guarantee of future operation
Client or Representative
Date
10 of 10
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
�> STE1,,1 OWNER & ADDRESS SYSTEM LOCATION
(example; left frons of house) _
DG�Dd�
U:\"i E OF PUMPING: QUANTITY PUMPED 13VD ALLUV)
NO !✓ YES SEPTIC TANK: NO YES (/
",ATURE OF SERVICE; ROUTINE EMERGENCY
uHl FRV:\TIONS:
GUUD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
-0.,.)l LM PUMPED BY:
L U,I'YI FNTS:
UN) l:'N' i'S TRANSHRRLD TO:
�r
FULL TO COVER
BAFFLES IN PL.ACF
LEACHFIELD RUNBACK .
FLOODED z
Q�HE(Z (EXPLAIN)
0
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER. MASSACHUSETTS
System Pumping Record
Fvmrli 4
DEP has provided this farm for use by local Boards of Faith. T`�he . ys em a Rec rd mus
be submitted -W -the i Soart#'tif`i eaiih or other apps oving ati[�afit� ���
A. Facility Info"nation JAN 2
tkag otd .. S� i2i3;.. TOWN L H DEPARTMENTORTH
ER
forms tor. the
compute2� P _1
use " r / P
only the tab key Address
* eve Y. -.v A/ --i� ti0 o ve- r
use the retumm CAy/Town State Zrp Cade
kms' 2. -Sj�m miner:
Name
Address (if different from location)
CRY rown Stat® Zip Code
• ��� G�2' S'33S
Telephone Number
B-7 Pumping Record
1. date ofPum in l �
Pumping Date 2. Quantity Pumped;
3. -Type of system: C3 Cesspools) septic Tank Tight Tank
Other (describe):
X
4. Effluent Tee Filter present? Yes,07NO
If yes, was it Cleaned? ❑ Yes [ . No
5. Condition of System:
6. System Pumped B
X01-
7. Location where cements utrgre, df
LS D
htmffinspect
tsfomnd.doc• obi
2-$o 7 ^jy�
Venicfe ticense Number
�` g Reoer�A • Page t cf t