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Miscellaneous - 9 INGALLS STREET 4/30/2018
N b � Z 03 Or c u Cn o m P Commonwealth of Massachusetts City/Town of NO. ANDOVER System Pumping Record Form 4 M 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab rearm A. Facility Information 1. System Location: 9 INGALLS ST. Address NO.ANDOVER City/Town 2. System Owner: DAVID DELANEY Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 6/5/12 Date UN 12-2012 N OF NORTH ANDOVER HEALTH DEPARTMENT 0 State State Telephone Number 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) N Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes N No 5. Condition of System: 6. System Pumped By: JAMES H. CURRIER Name J's SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD ?tyz: Signature o auler Signature of Receiving Facility Code Zip Code 1500 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 6/5/12 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 6134 Of NORTH 1ti e. J4 F _ p Town of North Andover s+�'- ;o �• �' HEALTH DEPARTMENT . ,S3 CHUS CHECK #: �� ATE: LOCATION:f✓, c1 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 $ ❑ TrasWSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Spector $ itle 5 Report ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. �ab Yj R, r r+ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA Property Address DAVID DELANEY Owner's Name NO.ANDOVER City/Town 01845 MA 01845 state Zip Code 6/4/12 131 Forest Stre MIDDLETON. MA 0 9 � (gift) 774-66 5, 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 enol of the form. A. General Information 1. Inspector: JAMES H CURRIER 11 1.J N `i `' Z0 Name of Inspector XS SEPTIC & DRAIN L�OWN OF iVOFlii AND V" Company Name LTH 01r[�ARTh41 NT 131 FOREST ST Company Address MIDDLETON MA 01949 City/Town 978-774-6685 Telephone Number B. Certification state 512327 License Number Zip Code I certify that 1 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 n Needs Further Evaluation by the Local Approving Authority In ector's Signature 6/4/12 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 shalt 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 . 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal S nSPecti 4 sposa ysticm' Page 1 of 1 Owner information is required for every page. lags SEMC a D AGN 131 Forest Street Commonwealth of Massachuse MIDDL.ETON, MA 01949 Title 5 Official licca Inspection Form (97811774-6685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA 01848 Property Address DAVID DELANEY Owner's Name NO. ANDOVER MA 01845 6/4/12 citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / akfays complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY B) System Conditionally Passes: ❑ One or more syst components as describers in the "Conditional Pass" sec ' n need to be replaced or repair The system, upon completion of the replacement pair, as approved by the Board of Health, !! pass_ Check the box for "yes", "no r "not determined" (Y, N, ND) for th ollowing statements. If "not determined," please explain. The septic tank is metal and over X years old*' or the se tank (whether metal or not) is structurally unsound, exhibits substa sal infiltration orjKfiltration or tank failure is imminent. System will pass inspection if the existing tank replaced a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if ' I structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is !e thanyears old is available. ❑ Y El F1NV(Explain belowr): t5ins -11110 Tide 5 Oficial tnspedion Foam: Subsurface Sewage Disposal System - Page 2 of 2 + JS t{c- C ok.4 b�fi Commonwealth of Massachusetts 131 Forest Street MIDDLETON, MA 01949 T We Official pec n Form (9781774.6685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANEY Owner Owner's Name information is required for NO. ANDOVER MA 01845 6/4/12 every page. City/Town state Zip Code Date of InspacGon B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observh- ion of sewage backup or break out or high static water level in the distribution box due to broken',gr obstructed pipe(s) or due to a broken, settled or uneven distribution boxm will pass inspe ion if (with approval of Board of Health): 101 are replaced ❑ obstructio?m is removed ❑ Y ❑ N ❑ ND (plain below): ❑ distribution lit is leveled or replaced ❑ Y ❑ N ❑ P6 (Explain below): :m required pumping more rill pass inspection if (with s )roken pipe(s) are replaced lbstruction is removed a year due to broken or obstructed pipe(s). The e Board of Health): ❑ Y ❑ N ❑ ND (Explain below): Y ❑ N ❑ ND (Explain below): Evaluati is Required by the Board of Health: is exi which require further evaluation by the Board of Health\erermine if m is ailing to protect public health, safety or the environment.will pass unless Board of Health determines in accordaCMR (b) that the system is not functioning in a manner which wblic health, rid the environment: 'esspool or privy is within 50 feet of a surface water 'esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Tale 5 official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 3 Commonwealth of Massachusetts Y's SEPT IC +& DRA Title 6 Official Inspection Form iillll?�978).t�tMA01949 • {97i3) 7746685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANEY Owner Owners Name information is required for NO. ANDOVER MA 01845 6/4/12 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will "l unless the Board of health (and Public {Nater Supplier, if an determines that t system is functioning in a /withj t protects the pu "c health, safety and environ ent: ❑ The system ha septic tank and soil absoem {SAS) the SAS is within 100 feet of a su t;e water supply or tributface wa supply. ❑ The system has a tic tank and SAS and with' a Zone 1 of a public water supply. ❑ The system has a septi tank and SAS anithin 50 feet of a private water supply well. The system has a septic tank and S and the SAan 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 a rmed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the pr ence o mmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no oth failure crit "a 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 dogged 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 ❑ ❑ 0Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins - 11110 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 4 Owner information is required for every page. Commonwealth of Massachusetts SEP-F#C as DRAT 9131 Forest Street MIDDLETON MA Title 5 Official Inspection Form (978) 01949 �74-sS85 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANEY Owner's Name NO. ANDOVER MA 01845 6/4/12 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 pipes). Number of times pumped:. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ 1 � Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ 41& 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 qualify 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Ej Large Systems: To be considered a large design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" questions in Section D. Yes No n the system must rve a facility with a "no" to eac f the following, in addition to the ❑ ❑ the system is within 400 fee f a s rface drinking water supply ❑ ❑ the system is within 2 feet of a trio ary to a surface drinking water supply ❑ ❑ the syst�VPA) m is lova d in a nitrogen sans 've area (Interim Wellhead Protection Area — o a mapped Zone li of a p lic water supply well If you have answered "yes" to an uestion in Section E the syste is considered a significant threat, or answered "yes" in Section D ve the targe system has failed. Th owner or operator of any large system considered a signifi t threat under Section E or failed under ction D shall upgrade the system in accordance with 10 CMR 15.304. The system owner should tact the appropriate regional office of the De rtment. t5ins - 11/10 V Title 5 of inial Inspection Font: Sutuurfaee Sewage Disposal System -Page 5 of 5 Owner information is required for every page. Commonwealth of Massachusetts Title 5 OfficialInspecti Form Subsurface Sewage 'Disposal System Form - Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANEY Owner's Name NO.ANDOVER CHylrown C. Checklist MA 01845 State Zip Corse 6/4112 'j"T' S -F - "PC a DRAW 131 Forest Street MID€ LETON, MA 01949 ''08) 774-6685 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions - Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 GPD isms - 51110 Title 5 Official to spectian Fame SubsurFace Sewage Disposal System •Page 6 of 6 11 Number of current residents: Does residence have a garbage grinder? ❑ J's SEPTNe.9 a DRAUN No Commonwealth of Massachusetts 132 Forest street Yes ® Title 5 Official Inspection Form �ID�97 a 6685��� ® Subsurface Sewage Disposal! System Form - Not for Voluntary Assessments No Seasonal use? 9 INGALLS ST., NO. ANDOVER, MA 01845 Yes No Property Address WELL DAVID DELANEY Owner Owner's Name information is required for NO . ANDOVER MA 01845 $14!12 every page. Cityfrown State Zip Code Date of Inspection D. System Informati®n Sump pump? [0 Description: No Last date of occupancy: 110 GPD X 3 BEDROOMS 11 Number of current residents: Does residence have a garbage grinder? ❑ Yes E No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage (gpd))= WELL Detail: Sump pump? [0 Yes ❑ No Last date of occupancy: �aRRENT Commercial/industrial low Conditions: Type of Establishment: Design flow (based on 310 CMR .203): Gallons per day (gpd) Basis of design flow (seats/persons/sq. ., etc. - Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ? ❑ Yes ❑ No Non -sanitary waste dischar3g to the Title 5 system? ❑ Yes ❑ No Water meter readings, i vailable: t5im- 1AN0 Title 5 Official Inspection Foam:. Subsurface Sewage Disposal System • Page 7 of 7 Commonwealth of Massachusetts J's SEPTja, & DRAgl 131 Forest Title 5 Official Inspection Fora €�ID(DIE �N�A'01949 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (�?$ X74-6685 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANEY Owner Owner's Name information is required for NO ANDOVER MA 01845 6/4/12 every page. citylTown state Zip code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: General Information LPD 2003 Was system pumped as parr of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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) 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 -11110 Title 5 {3ifrcaaJ inspection Farm' Subsurrare Sewage Disposal System •Page 8 of 8 D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NEW TANK IN 2003 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 16" feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 28' feet Comments (on condition of joints, venting, evidence of leakage, etc.): PIPES IN EXCELLENT CONDITION Septic Tank (locate on site plan): 12" Depth below grade: Beet Material of construction: ® concrete] metal ❑ fiberglass Q 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: 5' 8" X 10' 10" - 1500 GAL. Sludge depth: 4" t5ins - 11110 Title 5 Official Inspection Form- Subsurface Sewage Disposal System • Page 9 of 8 Commonwealth of Massachusetts T8 SEPTIC & DRAW Title 5 Official Ins c i Form 131 Forest Street MI00i..ETON, MA 01949 (9?�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ??4.6685 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANEY Owner Owner's Name information is required for NO. ANDOVER MA 01845 6/4/12 every page. Cityfrown State Zip Code mate of inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NEW TANK IN 2003 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 16" feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 28' feet Comments (on condition of joints, venting, evidence of leakage, etc.): PIPES IN EXCELLENT CONDITION Septic Tank (locate on site plan): 12" Depth below grade: Beet Material of construction: ® concrete] metal ❑ fiberglass Q 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: 5' 8" X 10' 10" - 1500 GAL. Sludge depth: 4" t5ins - 11110 Title 5 Official Inspection Form- Subsurface Sewage Disposal System • Page 9 of 8 Commonwealth of Massachusetts Fills 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANE`l Owner information is required for every page. owner's Nance NO.ANDOVER Cgfr wn D. System information (cont.) Q 01845 zip Code 6/4!12 J'S SEPTIC & DRAUM 131 Potfst Street M11DA)LE10N, MA 01949 M'78) ?74-&685 Date of inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8n Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PVC TEES IN PLACE AND GOOD CONDITION, LIQUID LEVEL CORRECT, OUTLET COVER TO WITHIN 6" OF FINISH GRADE_ RECOMMEND PUMPING AT THIS TIME. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete Elmetal ❑ fiberglass n3 ❑ pol ylene El other (explain): Dimensions: Scum thickness Distance from top of scum to Distance from bottom of s Date of last ��outlet tee or baffle to bottom of outlet tee or baffle Date \, [Sins • 11110 Title 5 oiticiai inspecwn Farts: Subsurface Sewage Disposal System • Page 10 of 10 Commonwealth of Massachusetts J's SEPTIC & DRAUN Title 5 Official Inspection Form Forest Street NitD'JLETt?ilf, MA 02949 (978) 774-6685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA01845 Property Address DAVID DELANEY Owner information is required for every page. Owners Name NO.ANDOVER cityrrown MA 01845 State Zip Code D. System Information (cont.) Comments (on pumping recommendations, inlet and liquid levels as related to outlet invert, evid nee of le 6/4/12 Date of Inspection et or baffle condition, structural integrity, etc.): Tight\bew g Tank (tank must be pumped at time of inspection) (locate on site plan): Depthde:Materruction: concree ❑ metal ❑ fiberglass ❑ polyethyler� ❑ other (explain): Dimensions: Capacity: gait Design Flow. gallons per day Alarm present: ❑ Yes ❑iso Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping:D\c). * ta Comments (condition of a2dflitches,e Atdch copy of current pumping contract (required). Is copy attached? ❑ �bs, ❑ No t5ins -11110 Tine 5 Official tnspettion Fomr. Subsurtate Sewage Disposal System - Page 11 of 11 Owner information is required for every page. Commonwealth of Massachusetts �$�, SEPTIC &4 �� �� Title Official Form 1 �IO131 Forest StreetDLL?t3N,I�IA01949 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (978) 774.66€35 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address DAVID DELANEY Ovmer's Name NO.ANDOVER Citylrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 &/4/12 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL AND WORKING PROPERLY, LIQUID LEVEL CORRECT, NO EVIDENCE OF CARRYOVER, D -BOX COVER WAS 12" BELOW GRADE. Pump Chamber (Io a on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments (note condition of pump amber, condition of pumps and appurtenances, etc.): Soil Abs6iption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 12 D. System information (cont.) Type: ❑ Commonwealth of Massachusetts number: ❑ teaching chambers ■ itle 5 Official Inspection Form �°� S3 oe trees ° 01949 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IUtrD(978) lel, MA. 74-668855 (978) leaching trenches 9 INGALLS ST., NO. ANDOVER, MA 01845 ® leaching fields number, dimensions: ONE - 20'X 40' Property Address overflow cesspool number: ❑ DAVID DELANEY Owner Owner's Name Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of information is required for NO. ANDOVER MA 01845 6/4/12 every page. City[Town State Zip Code Date of Inspection D. System information (cont.) Type: ❑ leaching pits number: ❑ teaching chambers number: ❑ teaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ONE - 20'X 40' ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL. Cesspools (cesspool must bll u 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 groutxfwater inflow t5ins -11110 as part of inspection) (loegle on site plan): "*'❑ Yes ❑ No Title 5 Official Inspection Form: Suhsutlace Sewage Disposal System - Page 13 of 13 ==�i= Owner information is required for every page. Commonwealth of Massachusetts J's SES` C & IMPIUm Title 5 Oficial Inspection Form 131 Forest Street MA 01 MIDI7LE'i alttMA 01948 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (978) 774.6685 9 INGAL.L.S S3., NO, ANDOVER, MA 01845 Property Address DAVID DELANEY owners Name NO. ANDOVER MA 01845 6/4/12 Cityrrown state Tip Code Date of Inspection D. System Information (cart.) Comments (note condition*soil, signs of hydraulic failure, level of ponding, condi ion of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of etc.): signs of hydraulic failure, leXel of ponding, condition of vegetation, t5ins • 11t10 Title 5 Oficial Inspection Foon: Subsudace Sewage Disposal System - Page 14 of 14 Commonwealth of Massachusetts ;' + RAW Title 5 Official Inspection Form DL 1•ar��rst01 NODI-��iV, MA 0194 ;978) 77-6685 Subsurface Sewage IDisposa! System f`o>Fort -Not for Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, NIA 01845 Property Address DAVID DELANEY owner Owners Name - requir information is NO. ANDOVER MA 01645 6/4112 required for every page. City/town store zip Code Date of 1rgX4 Dion D. System Information (cont.) Sketch Of Sewage Disposal System_ Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks_ Locate all wells within 100 feet. Locate where public water supply enters the building_ Check one of the boxes below. ® hand -sketch in the area below ❑ drawing attached separately e SOfficiaf Inspection Farts; Subsurface Sewage Disposal Systm -Page 15 of 16 • J s SEPTIC & DRAM Commonwealth of Massachl1SettS 131 Forest Street • Title le 5 Official cia Ins eci i n Form 82949 ��I;C(9Eif7l`I, M78) 685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,..'� 9 INGALLS ST., NO. ANDOVER, MA 41845 Property Address DAVID DELANEY Owner Owner's Name information is required for NO ANDOVER MA 01845 6/4/12 every page. CityfTown state Zip Code Date of Inspection D. System information (cola.) Site Exam: ❑ Check Slope Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 8.5' feet Please indicate all methods used to determine the high ground water elevation_ 1►e ■ Obtained from system design plans on record If checked, date of design pian 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: OBSERVED WATER LEVEL IN SUMP HOLE, LEVEL WAS 8.5' BELOW GROUND ELEVATION AT SEPTIC SYSTEM. Before fling this Inspection Report, please see Report Completeness Checklist on next page. Ki— - i vin TRte 5 Offislal fnspeCV= Fame: Subsulace Sewage Disposal System - Page 16 of 16 Commonwealth of Massachusetts A EPTUC & DRABN Title Official Inspection For MIDDLETO�N Forest Subsurface Sewage Disposal (37 ) ���-6685 _ g p System Form -Not far Voluntary Assessments 9 INGALLS ST., NO. ANDOVER, MA 01845 Property Address — DAVID DELANEY Owner iniormation is required for every page. owner's Name NO. ANDOVER MA 01845 6/4/12 CO Town state Zip Code. Date of inspection E. Report Completeness Checklist ® inspection Summary: A, B, C. D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate fife t5ins -11/10 Title 5 Official Inspection Form. Subsurface Sewage Disposal System • Page 17 of 17 NEW ENGLAND ENGINEERING SERVICES INC North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 9 Ingalls Road, North Andover, MA Dear Sirs: . November 25, 2002 Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely J5-,. C o Benjamin C. Osgood, 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION sr EA' F•..,• 262M 4 a m... _ J TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: R 1 AJ G -#L45- 12D uc 27M E4ND ajEdZ Owner's Name: :pmt p jD t i -*NE y Owner's Address: q -=M C-4 L US RC) No 2n.t AI CD Oar Q Date of Inspection: t-�Z.S7'1 O -Z_ Name of Inspector: (please print)$i t4T4AAw C- ©SG-oo,D " - Company Name: _oz— EWL,-L-4ti fl �tJCrl A+ E �z 42i N G.— Mailing Address: Ao ut uoz Ll c 6. 4 A.N D o,. c 2 .tAA Telephone Number: 9 7 g— 68 6_ L76 g CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000 The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority, Fails Inspector's Signature: 0, Date: !z 1a 6 Z The system inspector shall submit a copy of this in ion report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****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. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: q 2a 6-41," rA 4 r�o Qn-t N.J D pia 2 Owner: _ -VA%j1 o n Etd4�►1 C� Date of Inspection: (?,rj a Z Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired The system, ron completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not det ed (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal \0V20years old* or the septic tank (whether or not) is structurally unsound, exhibits substantial inexfiltration or tank failure is immin . System will pass inspection if the existing tank is replaced with a complying tic tank as approved by the d of Health. *A metal septic tank will pass inspection if it i cturally sound, not 1 ing and if a Certificate of Compliance indicating that the tank is less than 20 years old its ND explain: Observation of sewage backup or break out 'gh is water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or even distn tion box. System will pass inspection if (with approval of Board of Health): bro pipe(s) are replaced struction is removed distribution box is leveled or repla ND explain: The syst required pumping more than 4 tunes a year due to broken or o cted pipe(s). The system will pass inspect' 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: q Z13C,-A l,t.S pZ No RMI An! 1D oyr Q Owner: s?F}ut 17 D LArN 8 Date of Inspection: wr d 2- C. 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. Syglem will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the syste ' not functioning in a manner which will protect public health, safetyand the environment: ._ or privy is within 50 feet of a surface water — Cesspool rivy is within 50 feet of a bordering vegetated wet or a salt marsh 2. System will fail unless the Boa of Health (an blic Water Supplier, if any) determines that the system is functioning in a manner th rotects t public health, safety and environment: _ The system has a septic tank and sol , rption system (SAS) and the SAS is within 100 feet of a Surface water supply or tributary to a pifficNvater supply. The syste/septic and SAS and th AS is within a Zone 1 of a public water supply. — The systeand SAS and the SA ' within 50 feet of a private water supply well. The systeand SAS and the SAS is 1 an 100 feet but 50 feet or more from a private water sod used to determine distance zcttl:!�, passes if the well water analysis, performed at a DEP ified laboratory, for coliform volatile organic compounds indicates that the well is free fro pollution from that facility and the�ce of ammonia nitrogen and nitrate nitrogen is equal to or less ppm, provided that no other a'teria are triggered. A copy of the analysis must be attached to this fo 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S TN 6-ALLS QD 100 AMI N D c A Owner: Date of Inspection: I i a2, D. System Failure Criteria applicable to all systems: You must indicate "yes" or `5no" to each of the following for all inspections: Yes No -25 ,Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is Jess than 6" below invert or available volume is less than %Z day flow r Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. r Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private'water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic 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.] LK 2 (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 most serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You m indicate either`�+es" or `ho" to each of the following: (The folio criteria apply to large systems in addition to the criteria a yes no _ — the system is wi 400 feet of a surface g water supply — the :system. is within 200 fe tributary to a surface drinking water supply the m ted in a nitrogen sense ' area (Interim Wellhead Protection Area – IWPA) or a mapped Zoof a public water supply well If you have answered "yes" to any question in Section E the is considered a significant threat, or answered `Yes" in Section D above the large system has failed. The owner or for of any large system considered a significant threat under Section E or failed under Section D shall upgrade tem in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a _TN 6,41,L-5 RD Q ,N,q Owner: 240 0 O c LA 4j Date of Inspection: - It I S-1 a L 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 — --k/-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 ? Z_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffies or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? ✓_ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no ✓� Existing information. For example, a plan at the Board of Health. 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 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: q 1`N c,0 L Lj S i (LG G 6Q Q A4,4 Owner: Di4yi do LANcy Date of Inspection: i ZS-/ r.,?_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): -' Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: 3 Does residence have a garbage grinder (yes or no): je 5 Is laundry on a separate sewage system (yes or no): ga [if yes separate inspection required] Laundry system inspected (yes or no): -=- Seasonal use: (yes or no):.y Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): _/O Last date of occupancy: ! ,, r,r c ; COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meta readings, if available Last date of occupancy/use: OTHER (describe): Pumping Records GENERAL INFORMATION Source of information: Z oo ?c/L cam, ,mac A— Was system pumped as part of the inspection (yes or no): L1!> If yes, volume pumped: gallons - How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM peptic tank, distribution _ Single cesspool _ Overflow cesspool Privy box, soil absorption system — Shared system (yes or no) (if yes, attach previous inspection records, if any) _ InnovativetAlternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) — Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: -- . - . . ,. Were sewage odors detected when arriving at the site (yes or no): AeD Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: q yv 4-Ai_L s Sl -124F � Noanr s�N�a ,R AAA Owner: DAJ i D D I.ANE7 Date of Inspection: t s o 2 BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _Le6ist iron 40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): r ' S"%F SEPTIC TANK: _ (locate on site plan) I; Depth below grade: -" Material of construction: ✓concrete metal fiberglass _polyethylene other(explain) — — If tank is metal list age: — Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: L- -6 Sludge depth: I • Distance from top of sludge to bottom of outlet tee or baffle: 2 B, Scum thickness; z " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Zo „ How were dimensions determined: „„ o -,ns., 2 C s�-, cr_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 'i'A4JY. tN 6-0_'p Ga..p.TNp^ , GaACeC_ ' Tte-,s �•. Cre» a un D GREASE TRAP: 6Lojoocate 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: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4? :rN&-j#jigs C7 �oQ.TM PrrVDOJcQ.. Owner: i D DEVEi Date of Inspection: It I / o z TIGHT or HOLDING TANK: -Ah4 (tank must be. pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity. gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D 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.): - 'A t.1 a "A 0 �1an PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I /VbRTh' A-'J08JG'42 Owner: DAV-0_. P C./q.Vro� Date of Inspection: rT 4 '>,L SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: .-'leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 094rh of S4 L-1 2FM c_oa!<.s .v02na Al- CESSPOOLSW.+ (cesspool must be pumped as part of mspectionxlocate on site plan) Number and configuration: Depth - top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:/ /' f(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.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 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. 3-L Z3.y` PV • D r � Page It of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: R ,t MC,* L L s QZp No fvm AQP Zoe Q Owner- D Au t p S c ww E%/ Date of Inspection•jil ZS—! az SITE EXAM Slope 1 ado Surfacewater Check cellar Shallow wells, Estimated depth to ground water Li feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: 4 — 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: 6&& Tt 1N A& A T M #,9, L.., A3 P,+/Z" AL, y LL L 1 Aug 20 03 04:28p NORTH ANDOVER 9786889542 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT F a 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01943 Sandra Starr. R.S., C.H.O. t -sK 533S Telcpbonc (978) 688-9-W Public Hcalth Dirccter FAX (978) 6880542 August 2o, 2003 F.P. Reilly & Son, Inc. Fax: 978.475.3102 Attn: like Reilly F07 M -T, H3� Please note that your request for a Dbposd Works Consbactrata Penafit for a Tank Rglacemmt at 9 Ingalk Sfrcd submitted on August 13, 2003 has been reviewed. The permit can be approved with your agreement to the following con 'ons: 1. The garbage grinder needs to be removed ` 4'"A"PA 2. No stockpiling of soil on the teaching area1,4* ,,/3- Submit current water analysis to the Board of Health '? " I agree to comply with the above conditions: Mike Reilly, F.P. Reilly & Sons, Please sign your name if you will comply with the above conditions and fax back to the Health Department at 978.688.9542. We will then issue the DWC permit and leave in the pickup box. ?an ,LaGrasse Health Inspector /pfd p.1 2-d d12:60 co pa.2nd FAX COVER SHEET F -P. REILLY & SONS, INC. 206 Andover Street, Suite 11 Andover, MA 01810 (978) 475-1237 FAX (978) 475-3102 Date: 9-3 1 - 63 Fax To: _ _ 178 Tri - t -l2 i Ald 4 A G-C,,q SW' Company: �[yUyi F zVen TH1y OCv G- P Subject: 4' # of pages (including cover) _ r -- Remarks: ld dl2:co co a2 2nd �10RTH ot,,..° tia o t ► SSACHUSEt Town of North Andover, Massachusetts Form BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT Applicant Site Location %��J/15 1� Permission is hereby granted to Construct ( ) or Repair (individual Soil Absorp Sewage Disposal System as shown on the Design Approval S.5oft. Fee RMAN, BOARD OF HEA i. . D:W;C. No... // S 0 0 to z E 7d > cn m d 0 W 0 0 W t-' Zd Ili 'C t" rt " G a a G M M G £ G G M O H. N• M N- M 0 N 0 7 " G m m G o r• r n O N- N N a 5 rt 0 n 0 m a rt F1• ?J P. F 110 ii in P. a Q u a rr n a a a n iD a a m 4 0 0 O rt r• r- rt m ® G L4 �-Q a 0 a r• rt G H O D7 G iD cn rt N- i H tD tD O rt �5 M M a a a i1 M O CTI n r• G r• b L ro n >1 En n O a ro M 0 m 0 m O a rt 7d O C a m L n N r- rt G n b n ro 'O N• E £ N O N• a rt ri K a �1 0 5 M n G O 0 rt a 0 M 0 a M G r• 0 r- h 0 4 n ri a N x fn rt V n 0 rt H rt H < X X P. Qj a rt H. N rt rt 0 r• a UI N �i N � m G 10 � N 0 m IID N N• 0 'U V 'Ti H. In rt \� G 0 G O N (D rt rt a Ij N t-+ N r• r• 0 (D i rt rD r• rt rt rt rt n (1 m m O i V A � x m ro a to in in 41� {n {n to in to -v, in {n to to -(n in cn to 4111 in `$ � rt y LQ w rt tz O 1 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr, R.S., C.H.O. Telephone (978) 688-9540 Public Health Director FAX (978) 688-9542 FAX To: Mike Reilly From: Pamela F.P. Reilly & Sons, Inc. Fax: 978.475.3102 Pages: 2 Phone: 978.475.1237 — Office Date: 978.375.5697 — Cell Re: Disposal Works Construction Permit for CC: Sandra Starr, R.S., C.H.O. Septic System Health Director 0 Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: Attached a copy of the approved permit for Disposal Works Construction at: Please call 978-688-9540 for assistance with any questions. Thank you. Cc: File - Address File - Chrono Sandra Starr, RS., C.H.O. Public Health Director August 20, 2003 F.P. Reilly & Son, Inc. Attn: Mike Reilly Dear Mike, TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Fax: 978.475.3102 Telephone (978) 688-9540 FAX (978) 688-9542 Please note that your request for a Disposal Works Construction Permit for a Tank Replacement at 9 Ingalls Street submitted on August 13, 2003 has been reviewed. The permit can be approved with your agreement to the following conditions: 1. The garbage grinder needs to be removed 2. No stockpiling of soil on the leaching area 0' Submit current water analysis to the Board of Health I agree to comply with the above conditions: Mike Reilly, F.P. Reilly & Sons, Inc. Please sign your name if you will comply with the above conditions and fax back to the Health Department at 978.688.9542. We will then issue the DWC permit and leave in the pickup box. 7an ly, aGrasse Health Inspector /pfd 1?< FORM U- LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary, approvals/permits fro Boards and Departments having jurisdiction have been obtained. This does not rehei, the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SEC�'ION APPLICANT 1 l ! PHONE - 335- LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET l.J4. L� ST. NUMBER. ------------ Ul-VIGIAAL TwNs Ur FUWN AGENTS: CONSERVATION ADMINISTRATOR COMMENTS DATE APPROVED.. DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH COMMENTS C e&-ryb i%T DATE APPROVED. DATE- REJECTED iv PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOF Revised 9197 jm wlAer Cif) TE /5 J3 Route 28 . P.O. Box 900 Windham, NH 03087-0900 (603) 89874232 • Fax (603):898-9581 (800) 992 iPUMP visit us at www.pwpco.com WATER DAVID DELANEY Sample Number 13153 Sl(STEMS. 9INGALLS-ST.. Artesian Wells NO. ANDOVER, MA 01845 (97$)682 ' Pumps Booster Jet SAMPLE -FROM:. BEFORECONDITIONER: 9 INGALLS ST. NO.,,ANDOVER; MA O1"845 Submersible Sump Received (8/05/2003.05:00'PM) motor Controls ------ ---------------- -- - .--- : ---------- ------- ------------------ ----- ----- - --- Parts &&Accessories TestResults **** =Over MCL ` Maximum Contaminant Level Pipe & Fittings ---- ----11 ------ -,------------------- ----------------------------- ----- -- -- -- -- -- - Water Tanks pH ---------- ----- -- 6.0 ***. (6S = 8.5 EPA Sec Std). Hardness (as CaCO3) --- 51.3 .11" (75 PPM EPA Sec, Std) Iron ----- -------------- 1.0 **.** (0:3 PPM EPA Sec Std) SEWAGE Mangan --- --ese - --, .0.6 * (0:05 PPM EPA Sec Std) SYSTEMS Copper _ ---= --- ..2. (:1.3 PPM EPA Pri. Std) Alarm Systems Hydrogen Sulfide --- 0 PPM EPA Sec Std) Alternating Panels Total Solids,---- --------- 100: (50.6PP1VI EPA Sec Std) : Pumps -------- -- -- -------------------------- ------ -- -- --------- - - ---- _ Effluent --- ---- - -- --- --- - -- ---- Sewage Results entered by: Pails &'Accessories Pipe & Fittings This sample, meets EPA safe drinking standard's based on the tests listed above. Ifyou have any questions please call'Policy Well"& Pum .at 6037898-4232 ' WATER P. TREATMENT Aeration Filters Page 1:0f 1. "Cartridge:Filters Chemicals Softener Salt Well Sanitizer Neutralizers Reverse Osmosis Sand Separators Water Conditioners SERVICES 24 Hr. Emen Serv. Portable Puller Hoist Truck Water Testing 1 Providing Professional- Water Service Since 1966 IcL,tl� I 9)\J-1 � -A "TOWN OF NORTH AN®OVE BOARD OF HEALTH 1! ter' Location Permit # Food Service Retail Food $ Limited Retail $ _ Seasonal $ Disposal Works Installers $ Disposal Works Construction$- Soil Testing $ Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ Offal/Trash Hain $ Other 6,7- 7031 J Health Agent White - Applicant Yellow - Dept. Pink - Treasurer APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 13-0 ) CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER: P �P ��`( S� `��,rsL SIGNATURE: _ TELEPHONE# 9 n 2= *\ S-I'aii CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Fee Attached? Foundation As -built? Admin" trative Use Only Yes No Yes No Floor plans on file? Yes No_ A r v pp o a Date: I ' t ------------- NZ PW 0Jl,L — So l,O- ZI 0 � xr p Yi f . a a KXi1J ' 3 � z 77 p �- '0014a �. I z l Maj � } � 2 V v z z '0014a �. I z in0 w z z in0 w