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HomeMy WebLinkAboutMiscellaneous - 793 WINTER STREET 4/30/2018 (2)N O p�p CO [A w r Z O -i M A X C. O m o m o m c 4 FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT G� �f�, 4Jr�J PHONE C�Z�a1yS� ASSESSORS MAP NUMBERP D t�. 3 LOT NUMBER % SUBDIVISION LOT NUMBER OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS ............................................................................ J�. CONSERVATION ADMINISTRATOR COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE. REJECTED DATE APPROVED FOOD INSPECTOR - HEAL �, DATE REJECTED DATE APPROVED „ f SEPTI SPECTOR - HEALIH 1/ DATE REJECTED PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTN IENT DATE REJECTED CON94ENTS RECEIVED BY BUILDING INSPECTOR DATE AS 6 u I LT PIAN Cv N WINTER SP S T. No. t-,NoovEp, MASS 'A% R. IN 16 L L O.0 'A I Lo -T W. ov P-OVS E ;EWER )f TAyK INCE? T ANK Oul L 17 T Fps L E1 152 00 O;j7%.E T 1. 50 L P40 OF L1.4;: ISI. 400 4 C.Z. PIPE N 3-r IN ROBERI W. x SMITH 13 — 1(0.14051 44 co Povs E GA .1 PT, L 7A Ng co 0 4�W, je,- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 793 WINTER STREET, NORTH Owner's name MARTIN J. KILLOURIE Date of Inspection JULY 81 1995 PART A CHECKLIST Check if the following have been done: ANDOVER, MA 01845 Y Pumping information was requested of the owner, occupant, and Board of Health. Y 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 not been introduced into the system recently or as part of this inspection. Y As built plans have been obtained and examined. Note if they are not available with N/A. Y The facility or dwelling was inspected for signs of sewage back-up. Y The site was inspected for signs of breakout. Y All system components, excluding the SAS, have been located on the site. Y The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Y The size and location of the SAS on the site has been determined based on existing information or approximated by non -intrusive methods. _ Y The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 4 number of bedrooms 2 number of current residents NO garbage grinder, yes or no NO laundry connected to system, yes or no LAUNDRY GOES TO A DRY WELL NO seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: NIA PRESENT Last date of occupancy GENERAL INFORMATION records and source of information: NO System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system X 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: SYSTEM INSTALLED BY OWNER WHEN HOUSE WAS BUILT 1979. NO Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: Y (locate on site plan) depth below grade: 2'-8" material of construction: X concrete metal FRP other (explain) dimensions: 1500 GAL. SEPTIC TANK. 5.8' x 9.8' x 4.8' 1" sludge depth 4'- 1 " distance from top of sludge to bottom of outlet tee or baffle 0" scum thickness 0" distance from top of scum to top of outlet tee or baffle NO SCUM LAYER 0" distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc.) DISTRIBUTION BOX: Y (locate on site plan) 0" depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) TILL' TWIV TQ T nrA?`L`T At 011 DL'i nVIT d""nTT1ATT% 7 VIETVIr TT To T 11719MIT A1►TTl PUMP CHAMBER: NO (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS): Y (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number 1 FIELD - 3 LINES. AREA 25' x 40' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) NO EVIDENCE OF PONDING OR SMELL. SOIL IS GOOD AND CLEAN. CESSPOOLS (locate on site plan): NO 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: NO (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, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' SEGTC;W - NT -6 L —..\N A 5 H nRY �N�LL. N stc.T►o � D%5-tQ��t3��v*l 150 DEPTH TO GROUNDWATER > $' depth to groundwater PLAN VIEW NTSmethod of determination or approximation: STIFFL 1.10 PRuM 1 5da 4N/ . SEGTC;W - NT -6 L —..\N A 5 H nRY �N�LL. N stc.T►o � D%5-tQ��t3��v*l 150 DEPTH TO GROUNDWATER > $' depth to groundwater PLAN VIEW NTSmethod of determination or approximation: Martin J. Killourie 793 Winter Street North Andover, MA 01845 � sr I j pNw • � I ,ELAND. m 133 FAKM KD r9y� : • Q KIA E3v I!/ 9 Q' j �h rrirrt � G F ' : �IRD- � I .Stereos 1 Afm i p + fp i i Pu ETpN ( C _ rf' Py 1 = \ P V \LZ. oa`oa =RIDGE IK N 0 t t7 WEST PAgR/BOXFORD'a+ANDtEa ( �o`o`'�\ e r /'.__ Q� p • Z y,( p�N 8� �� . s ilanrti �� ARM ao � a/'u,u; Bo\tord .' W vim• w lout � Rnnl O Q' LIBERTY i til � II_ 1 m... I Ct•Ettlrarn Ex 10 n hDDh RD ;' � •~a Sl at i' van Sr K,MBER AvND. MAIi A I 114 y y1 . n '3 � 0 TI R ER0 x l! P o \� o MAIN �qiy No 1EMc I RNo ooy?!e4Sl NORTH A AND; • VER W\NZER_ i 3 H' r ST I O � � I I I a j � X I Q� p • Z y,( p�N 8� �� . s ilanrti �� ARM ao � a/'u,u; Bo\tord .' W vim• w lout � Rnnl O Q' LIBERTY i til � II_ 1 m... I Ct•Ettlrarn Ex 10 n hDDh RD ;' � •~a Sl at i' van Sr K,MBER AvND. MAIi A I 114 y y1 . n '3 � 0 State Forest I l! P QQQ Flit o \� No Q� p • Z y,( p�N 8� �� . s ilanrti �� ARM ao � a/'u,u; Bo\tord .' W vim• w lout � Rnnl O Q' LIBERTY i til � II_ 1 m... I Ct•Ettlrarn Ex 10 n hDDh RD ;' � •~a Sl at i' van Sr K,MBER AvND. MAIi A I 114 y y1 . n �• IN G R0VW0 AS EUILT PLAN vVINTER ST. No. AMvovER, ASS LO7 4 CES1c,NEo F02; MQ,RTIN K1L.L0VPI Ey l�oeaRT w, sM►T%-1 SCJ e �^ 34 J Wi CC E r� HOUSE o TANK INET ANK JVTL T 154.43 M4 Pr 00 ROBERT G to �90 FG �P =G G Z. P1PF NOT IN 8050 T o W. SMITH `" M4 Pr ROBERT G W. y O SMITH y �90 FG �P f S'f 6\yk. I �SlONA<-6a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) N Backup of sewage into facility? N _ Discharge or ponding of effluent to the surface of the ground or surface waters? N Static liquid level in the distribution box above outlet invert? N Liquid depth in cesspool < 6" below invert or available volume < 1/2 day flow? N Required pumping 4 times or more in the last year? number of times pumped 1 N Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: N below the high groundwater elevation? N within 50 feet of a surface water? N within 100 feet of a surface water supply or tributary to a surface water supply? N within a Zone I of a public well? N within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS)? N within 50 feet of a private water supply well? N 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector GORDON A. BROZ LICENSE NO. 37444 Company Name AMERICAN SEPTIC INPECTIONS Company Address 49 ORCHARD STREET MERRIMAC, MA 01860 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the properfunction and maintenance of on-site sewage disposal systems. Check one: X I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature ����� Date JULY 1 , 5 Original to system owner Copies to: N. ANDOVER BOARD OF HEALTH Buyer (if applicable) Approving authority FORK U - LOT REIZASE 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: Rp ge, Tpv-tscN. Phone LOCATION: Assessor's Map Number Parcel Subdivision Street 4+ W I tl� QT Lots) St. Number ************************Official Use Only************************ RECOMMENDATION S : F A TS: Date Approved 12 ///1 S` Conservation Admin str for Date Rejected Comments �p�� G'Xi���1 41,vy'y�iC�� Si(,c}�r� /26 W01w\"6S C6(` Town Planner Comments Food Inspector -Health ,,,,8eptic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Atfproved Date Rejected Date Approved Date Rejected Date Approved z ::�Zi� Date Rejected Received by Building Inspector Date TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 1"EI�l OWNER & ADDRESS dvl� , UR i . � AN— �8f 1 OF AEALl SYSTEM LOCATION ((!xample: left front of houst) tf -�(atv� L) \'!'E OF PUMPfNC: © (QUANTITY PUMPEDL`;�, .�)SPUOL: NO YES SEPTICTANK: NO YES "PURE OF SERVICE: ROUTINE MERCENCY Ali>FRV \TIONS: C OOD CONDITION HFAVY CREASE 1A ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER ,l ) I LM PUM1)CD BY CCS%/ UJ I "d CN'TS: U* I !:'N'I"5 T)I ANSFEIZIZLD TO: FULL TO COVC z _ BAFFLE'S IN PL.ACh' LEACHFIELD IzUNUACK,. FLOODED O�HFR (EXPLAIN.)