The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 90 WINDSOR LANE 4/30/2018 (2)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. It�l l5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l � 90 Windsor Lane Property Address Will Edwards Owner's Name North Andover MA 01845 12/19/2012 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist.at the end of the form. A. General Information 1. Inspector: Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover MA City/Town State 978-475-4786 S115 Telephone Number License Number B. Certification 01810 Zip Code 1 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 urther Evaluation by the Local Approving Authority 12/19/2012 Inspecfo s Signature U Date ❑ Fulls r TET 2E 201z h� 1 TOWN OF NORTH ANDOVER HEALTH CEPARTMENT The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional, office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,: and the approving authority. ****This'report only describes. conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. < Us 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 1 of 17 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y� 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. Citylrowh State Zip Code Date of Inspection B. Certification (cont.) t5ins • 11110 Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y El N ❑ ND (Explain below): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout or high static water. level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction.is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance.with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins - 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property.Address _ Will Edwards Owner's Name North Andover MA 01845 12/19/2012 CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning in a.manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS. is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well_*.'. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. $,,. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or, system component due to overloaded or. clogged SAS or cesspool .❑ ® Discharge or ponding .of 'eftluent to the surface of the ground or surface waters due to an overloaded or clogged SAS. or cesspool ❑ z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow 61ns • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool'or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ Q 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 El ❑ 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 ydu have answered "yes" to any question,in;Secfion 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'VAth 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17. Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code C. Checklist 12/19/2012 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 ❑ z Were any of the system components pumped out in the prev ious.two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? _ ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. 'For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 90 Windsor Lane v . Property Address - Will Edwards Owner Owner's Name information is North Andover required for every page. City/Town D. System Information Description: MA 01845 12/19/2012 State Zip Code Date of Inspection Type of Establishment: Design flow (based on.310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? IndUstrial waste holding tank.present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes 2 No ❑ Number of current residents: ❑ No ❑ Yes Does residence have a garbage grinder? 0 Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on.310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? IndUstrial waste holding tank.present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposai System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: date Other (describe below): General Information Pumping Records: Source of information: Pumped .Nov. 2012 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: z 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. ❑ Othert(describe): t5ins • 11/10 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 90 Windsor Lane Property Address �... ,.__...�._ Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 26 years old, 8/2/1986,As built plan. Outlet tee in septic tank, outlet pipe to d -box & d -box was replaced 11/19/2012, permit at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.8 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition, of joints, venting, evidence of leakage, etc.): 4" cast iron thru wall, 3" PVC in house. Septic Tank (locate on site plan): Depth below grade: 8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age:. .. .. .. ..... . ... years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 0 ❑ Yes ❑ No t5ins • 11/10 Idle 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 27" 9 W Distance from bottom of scum to bottom of outlet tee or baffle 21" How were dimensions' determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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: t5ins -11110 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): .Dimensions: Capacity: Design Flow: gallons gallons per day Alarm present:. ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence.of solids carryover, any evidence of leakage into or out of box, etc.):. D -box level & distribution equal, has flow levelers. No evidence of leakage. No evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for. North Andover MA 01845 12/19/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 61' ;..❑ , leaching fields number, dimensions: ❑ overflow. cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation; etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins •:11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. Cityrrown State Zip Code Date of Inspection D..System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, t5ins • 11/10 Title 5 Official inspection Forth: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage. Disposal System Form - Not for Voluntary Assessments y( 90 Windsor Lane v Property Address Will Edwards Owner Owner's Name information is required for North Andover MA 01845 12/19/2012 every page. City/town State Zip Code Date of Inspection 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 f t�eu� t� v, 'N U r -40 C LA I lo it t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner's Name North Andover Citylrown D. System Information (cont.) Site Exam: MA 01845 12/19/2012 State Zip Code Date of Inspection ® Check Slope ® Surface water ® Check cellar ® Shallow wells -Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4/22/1985 Date '❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design. plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Windsor Lane Property Address Will Edwards Owner Owner's Name information is North Andover MA 01845 12/19/2012 required for every page. City(rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A,.B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information —Estimated depth to high. groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 12/17/2012 3:13:45 PM by Maureen McAuley Town of North Andover Tax Map # 210-106.D-0069-0000.0 Parcel Id 17826 90 WINDSOR LANE EDWARDS, WILLEY JOE 90 WINDSOR LANE N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2013 UB Mailina Index Name/Address EDWARDS, WILLEY JOE 90 WINDSOR LANE N. ANDOVER, MA. 01845 UB Account Maint. Account No Cycle Bldg Id. 13416.0 - 90 WINDSOR LANE 2100061 02 Cycle 02 UB Services Maint. Account No. 2100061 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 2100061 Type Loan Number Payor Active/Inact. From Occupant Name Active/Inactive Last Billing Date 12/6/2012 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 72.20 /1 Serial No Status Location Brand Type Size YTD Cons 35487174 e Active ERT HH b Badger w Water 0.63 0.63 37E Date Reading Code Consumption Posted Date Variance 10/30/2012 381 a Actual 19 12/13/2012 -290/c 8/1/2012 362 a Actual 27 9/26/2012 590/c 5/2/2012 335 a Actual 17 6/20/2012 23% 2/1/2012 318 a Actual 14 3/14/2012 -650/c 11/1/2011 304 a Actual 39 12/15/2011 -230/c 8/4/2011 265 a Actual 53 9/14/2011 2030/c 5/3/2011 212 a Actual 16 6/13/2011 17% 2/7/2011 196 a Actual 17 3/15/2011 -670/c 11/2/2010 179 a Actual 49 12/13/2010 -25% 8/2/2010 130 a Actual 63 9/13/2010 334°/r 5/5/2010 67 a Actual 15 6/9/2010 6% 2/2/2010 52 a Actual 14 3/11/2010 -9% 11/3/2009 38 aActual 15 12/11/2009 -9% 8/6/2009 23 a Actual 18 9/11/2009 34% 5/1/2009 5 a Actual 5 6/16/2009 -1000/( 3/26/2009 0 n New Meter 0 6/16/2009 -1000/( 3/26/2009 2278 r Replacement 2 6/16/2009 -840/c 2/2/2009 2276 m Manual estimate 21 3/16/2009 3% MSG 11/5/2008 2255 a Actual 21 12/10/2008 -320/c 8/5/2008 2234 a Actual 32 9/12/2008 100% 5/1/2008 2202 a Actual 15 6/18/2008 -15% 2/1/2008 2187 a Actual 17 3/14/2008 -350/( 11/6/2007 2170 ' a Actual 29 1/15/2008 420/c 8/1/2007 2141 a Actual 19 9/14/2007 230X 5/3/2007 2122a Actual 11 6/22/2007 10X 2/28/2007 .2111 " m Manual estimate 20 3/23/2007 -50/( 11/2/2006 '2091 a Actual 13 12/22/2006 -640/c 8/21/2006 2078 a Actual 44 9/13/2006 121OX PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 11/19/12 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box and Tee repair By: Bateson Brothers At: 90 Windsor Lane Map 106D Lot 69 North Andover, MA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent COPY 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com so .,V North Andover Health Department fommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 90 Windsor Lane MAP: LOT: 6 INSTALLER: Bateson Brothers DESIGNER: D -Box T -In tank DATE: 11-19-12 BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing X Inlet tee installed, centered under access port w - Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement X Installed on stable stone base X H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) r Alk SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to. header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = r. SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1001 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Commonwealth of Massachusetts Map -Block -Lot BOARD OF HEALTH 106.D0069 106. --------------- Permit No North Andover BHP -2012-0753 ----------------------- FEE $125.00 ISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson ------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. ; -, n L at No 90 WINDSOR LANE �U I Fo ---------------------------------------------- --- - - - ------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP -2012-075 Dated October 26, 2012 ---------------------------- Issued On: Oct -26-2012 ----------------------------------------------------------- BOARD OF HEALTH °f MO;'" •1,�, Application forSeptic Disposal System /®-� 3: •��•' `' �' �°c Construction Permit —TOWN OF TODAY'S DATE �o ORTH ANDOVER, NU 01845 $ 2s oo —Full Repair � r" � C.. ` 125: -Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component— What? P'°`'� cursor - do not use the return A. Facility Information key. � 0 V✓f/t/�Srs2 4N. rad Address or Lot # lel City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name Address (if different from above) Ale City/Town 3. Installer Information Name Address City/Town 4. Desigi Name Address City/Town 141A State Telephone Number 69 ! s'J-16_ Zip Code BATESON FNrFcpglS-ES; Name of Company f t t ARGILIA ROAD �,. ANDOVER, MA 01810 State Zip Code 79 T/S— 4'7,9 Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 TODAYS DATE $.250.00 - Full Repair $125.00 - Component PAGE 2 OF 2 A, Facility. Information continued.... 5. Type- of Building: residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to.ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issue y this Board of Health. Name Date Applicata pprdved By: and of Health Representative) N eDate Application Dis proved. f he following reasons:" For Office Use Only: 1 ''Fee Attached?: Yes No 2.. ProjectMabager Obligation Form Attaehed? Yes No 3.: Pump Svstem? Ifsoo Attach conn ofElectrical Permit` . Yes No 4. Foundation As Built.? (new construction ronly)r Yes_ No (Same scale as approved plan) 5. FloorPlans? (hew construction only). Yes_ No 4piidiNdn'for•D(spg5a1 Systerii:06n*uctioh Perris t % Page 2 4f 2 SEPTIC SYSTEM.INS' -SYSTEM.-INSTALLER EI�'�'RGJE MANAGEMENT As the North Andover,licensed Installer for the constmeti.on forthe septic system .for.the property at For pians by (Address of septic system) Relative to the -application of And dated (Installer's name) Dated `� —�5 — �-- With revision &Vaylsdate) I understand the following oliligations fur management of •this project: ; i. As the installer, I am .obligated to obtain. all permits andBoard of Health approved plans prior to performing any work on a site: I must have the . roved titans and then eftnit on site when any work is beim; done_ 2. As the installer,.I must call for any and aH'inspettions: If homeowner, contractor,.project manager, or any company schedules -an inspection and the system is not ready, then other person not associated with my item three- shall, bo. applicable. As .tl ' installer, Iatm.-recjuired to, have .tlie necessary woik'completed•prioi,to the .applicable inspections as indicated below. I tiYtclef§tand that riQul'e'stinitanihsEmcdon without comtiletion: of the items in. accordant _ _ _ .. __ ,____yam•:_ _ Qen nn �.,e.1.n;:,:.l..n,...� �M,,,,et.mAanrl/n of : Botfo'm of Bed Generally, "-is the•j6xst.(.1 inspection pnless.,ihere is a retaining wall, which s6iu a•bedri&e< t: The instaO must��guest the kspectidfl but sloes' not have to be present. b. Final-Constn 'C&A-Iospeetiori — Engiaeer mvst `first ; do them inspection for elevations; •ti'es, etc. As-t�iiilt of'vetbal OK (or e-mail•to: l_iealtlideit�t ofriorthandover.com�: from the engineer must be stibmijtfed-to-the.Bo'ard-of Health, aher.whicli InstalQex.ca3ls for:an inspection time. Installer must bepresent for this inspection, With -a pump System, all electrical'work:must be ready and able to causepump.to•tdorkarid;alarM, .tofiuiotion.. C . Find1�G•, Lade �5taller must request inspection Wh . `411 din complete.. Installer does not have to be on-site. 4. As -the installer,' I understand that only I•pezform the .work. (other than :simple excavation) and I am required to complete the -installation of the system identified in the, attached application for installation::I further 5. As th'e.•instiller,.I understand that I xnust$e•on-size during tho.p&f6iniance of the following construction, steps:.. a: Determination athat.theproperelevation of the excatratron has been reached. b. Inspection ofthe `sand and stove to be used. c. Final inspecdoa by Board of.Kealth staffor consultant. d. Installation., oftank, D Box pipes, stone, vent, primp chamber, retariirrg wall and other components W Undersigned Licensed Septic.Ias,.tallez: SdN. TN itne, = Print) 4.f � RZ 1 S Laf /N►E o z= /NSpEC •z� , 3.2' 9Z 7LRENCA es 44/x ea ter �UgETTS ti 1 71gL A/ AJ �"�— / d x E/�/,� i 0 L /NE �� s-• o Laf /N►E o z= /NSpEC •z� , 3.2' 9Z 7LRENCA es 44/x ea ter �UgETTS ti 1 20413b of NoI�T'M Ati�v�l�, MA, A PFKp\J t�v ('--O/JPiTiO"5 DI5APPKU V5p Rt�6soNs (�J tG� 5vi'PL7 SEPT 1 c3' s TEl-1 ?ESI 6A PArt' D/J i E 'f - 16 �1\- -45 Oer Cur Fog hof) IS Tco -LL-T)5e61 R0CF5 STWT6( 1 06/Pll N D StPT'(� SySTENt wST/311,t1T�n�U 4-: X4V4TOo J 1AJSn-.6-po&j �Ss ' El F-4�� FW,QL I �15PFGjlon� /� PPj�dV E,D 14'PD(T(pA--)AL- 1,,%j5F-Exi (oNS �lF-,O►'y� DISAPPIZUv6p D,arC r R�So NS •� FOAL APPROVAL Apt-Ro, Vl/vG AUT-HO/-��T,/ DATA�7-1 APP)�ovrJG