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Home My WebLink AboutMiscellaneous - 91 CROSSBOW LANE 4/30/2018ti " N J 0 � 0j 0 i 0 N Cn W O 0 O i O Z j O rt'b D North Andover Board of Assessors Public Access t Np oTM 1 ,A cwus Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial �• Page 1 of 1 x North Andover 4 Assessorl GZroperty Record Card ,ation: 91 CROSSBOW LANE Ener Name: HOLLORAN, MARTIN J LESLIE D HOLLORAN mer Address: 91 CROSSBOW LANE City: NORTH ANDOVER State: MA Zip: 01845 ighborhood: 7 - 7 Land Area: 1.01 acres - Code: 101-SNGL-FAM-RES Total Finished Area: 2710 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR :al Value: 609,400 643,200 ilding Value: 383,700 418,400 id Value: 225,700 224,800 rket Land Value: 225,700 apter Land Value: http://csc=ma.us/PROPAPP/display.do?linkId=1519080&town=NandoverPubAcc 6/16/2010 Commonwealth of Massachusetts City/Town of 4System Pumping Record �Form 4 DEP has provided this form for use -by local Boards of Health. Other forms may be used, but the information• must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left a of house Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address c) v, City/Town State Zip Code 2. System Owner. Name' Address (if different from location) City/Town • StatE�---�� v 71p Code Telephone Number B. Pumping Record 1. Date of Pumpingdate 2. Q tity Pumped: Gallons -� 3. Type of system: ❑ Cesspool(s) ;Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If. yes, was it cleaned?D Yes ❑ No, 5. Conditionp.System: 6. System Pumped By: 1, RECEIVED Neil Bateson Name Bateson Enterprises Inc Company 7. Loca ' ere contents were disposed: G.l` S'. Lowell Waste Wi YVT w F5821 License TOWN OF NORTH ANDOVER HEALTH DEPARTMENT �5-- N - ( Y f Date t5form4.doo- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts (.ihdTown of e DSC 11 X012 System Pumping Record < F TOWN OF NORTH AMM ER Form 4 HEALTH DEPARTMENT DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / ' 'de of house Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Ot City/Town 2. System Owner. %-) CAA -C. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): CC) -B- Q) — 2. Quantity Pumped eptic Tank I'Lf -eA F" State Zip Code state Zip Code 07 -- Telephone Number Date Cesspool(s) Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9—wo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition f System: 6. System Pumped By.- Neil y:Neil Bateson Name Bateson Enterprises Inc Company 7. Le contents were disposed: C. L S. Lowell Waste Water A : � 71"tf':. F5821 Vehicle License Number Date La "-� —� -'�- t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of T a System Pumping Record MAY 5 2010 Form 4 TOWN OF NORTH ANDOVER HEAL H DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forrrr,771 lay VV UQVU, information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of housfight :sid��of Left front of house, Right front of house, Left rear of house, Right rear of house. eft rear of building. Right rear of building. Address q1 City/Town State 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Zip Code StateZip Code '31 Telephone Number 2. Quantity Pumped eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: R 7 i t5form4idoc• 06/03 System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company Location where contents were disposed: 4 /, Lowell Waste Water of F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 I C'ER'M ASS H'U provided Jhfo loan t9t loco) 60a, or culof �fyln f�orrtl� Ion TOWN OF NORTH AND •,� ri te,-. HEALTH DEPARTMENT lo_ w Till, ......................... . ... . 77, 1441 µ i ---------- --- • P-Pumping-Royord, 08 ;o 9.1 Pvmpinq,� fmom:Cs s�ool(9) Cimic Tat),k lar. Mon( Too Fl!(o( p C'Qanoo? 37" 0 7.".. 3 ooAl Vyl m 8 Q Y/I 0 6 oi/iPpigy'l, RECEIVED TOWN OF NORTH ANCKJVE -%JUL - 6 2005 SYSTEM PUMPING RECO RL TOWN OF NORTH ANDOVER HEALTH DEPARTMENT ADDUOO SYSTEM L 0 -C -A-7-0-7 rl- 1 Sf c - DATE OF PUMO: ...-QUAN71TY PUMPED: NA rUK8 OF nRyleFE: tm6p 0b3V.AVA-noN3: 000D CONDITION FU LL'TU Lo V trX tMAVY O BAMBS IN PLAQL-. Rom LEACHFIF-LD RLNBACK SXCB$Styg SOLIDS FLOODED SOLrD CARXYOYIF,,-.-, 07YER EXPLAIN C�70 177a. m +r TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD `4 d / //��Z S1'STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED/63O GALLONS CC'S.SPOOL: NO i/ YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACH ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O" HER (EXPLAIN) LM 'PUMP ED BY . //.�" C'U' INIENTS: cONTENTS TRANSFERRED T0: pORTH O��t�,a0 �bgti0 0 O'9. COMIC MCWKK 1' PUBLIC HEALTH DEPARTMENT Community Development Division CE1271rFICA�I'E OF C091�1�LIANC� As of: June 3 0, 2010 This is to cert that the individual su6surface disposal system received a SArIISTACTOR TINSTECTIOYof the: !RfpCacement of a Component: oistri6ution Box For an On -Site Sewage qxTosa(System By. ToddBateson t 91 Crossbow Lane JKap-106.x; 2'arcef— 0207 NortFiAndover, 911A 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. _i an Sawyer, yfS/ (Pu6lic Aealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com TOWN OF NORTH ANDOVER4 NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES 1%-R "0 °gNOOL HEALTH DEPARTMENT o . d 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 sACHUs Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION. NOTES LOCATION INFORMATION ADDRESS: q/ r,v0-55 MAP: LOT: INSTALLER:5� DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: / /.5 o2Ul� DATE OF BED BOTTOM INSPECTION. DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS []Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer Comments: []Topography not appreciably altered . SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVERNaRT„ Office of COMMUNITY DEVELOPMENT AND SERVICES � bt;w., •6 O HEALTH 'DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 ,€ NORTH ANDOVER, MASSACHUSETTS 01845 SACHUS Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1.000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over ❑ pump access port Water ig!!mess of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation — Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER f NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES 3� p`eo 16.1 HEALTH DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 C "ec�h SACHUS Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 - FAX D -BOX 701 Comments: SOIL ABSORPTION SYSTEM EJ El El Comments: Installed on stable stone base Inlet tee (if pumped or >0.087foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not.required) Bottom of SAS excavated down to soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 Y2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed Laterals installed and ends connected to .header Laterals vented if impervious material above Orifices @ 5 & 7 o'clock positions Gravel -less disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan Wastewater System Documentation — Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER o< NORTM q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ~ a A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 s�cHus Susan Y. Sawyer, REHSaS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION Comments: CONTROL PANEL Comments: -- inch manifold laterals installed with end sweeps size: material: Squirt test ft in height Equal distribution to all laterals orifice size inch as per plan ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Wastewater System Documentation — Feb 2006 Page 4 of 6 Wd TOWN OF NORTH ANDOVER 00RT►{ Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p y A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �9S "° 's Hu Susan Y. Sawyer, REHS/RS 978.688.9540 —Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ❑ Property line Tank 10 SAS Sewer ❑ Cellar wall 10 10 20 �] Inground pool . 10 20 ❑ Slab foundation 10 10 El Deck, on footings, etc 5 10 El Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑, Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 Wetlands bordering surface I Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesse s r distance (NA 5.02). 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 Wastewater System Documentation — Feb 2006 Page 5 of 6 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 I Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesse s r distance (NA 5.02). 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 Wastewater System Documentation — Feb 2006 Page 5 of 6 TOR'N OF NORTH ANDOVER f HORTN Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MAS SACHUSETTS 01845"Ss,�H�S�K`� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 w �? ap't Commonwealth of Massachusetts Map -Block -Lot 10620207 Board of Health Permit No North Andover BHP -201-0-06-- ------------ - - ---- P.I. FEE �s cNuti F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson to (Repair -DISTRIBUTION BOX ONLY) an Individual Sewage Disposal System. at No 91 CROSSBOW LANE as shown on the application for Disposal Works Construction Permit No. BHP -2010-061 Dated June 02 2010 ---------------------- ------------'---------------- --- ------------------------------------ Issued Ori: Jun -02-2010 Board of Health Map -Block -Lot 10630207 Commonwealth of Massachusetts Map- ,• a4 b°c106^60207 r Board of Health North Andover +�CwuACwi' M�6ti CERTIFICATE OF COMPLIANCE �SS THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -DISTRIBUTION BOX by Todd Bateson -------------------------------- ------------------- ----------------------------------------- Installer at No 91 CROSSBOW LANE has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2010-061 Dated _ _ _ June 02,_ 2010 ------------------------ - - - - --------- ----------------------------------------------------------------- Printed On: Jun -16-2010 Board of Health ---------------------------------------------------------------------------------- A 4NTy Commonwealth of Massachusetts Map -Block -Lot 3��4t��s� 106.B0207 - ------------ ---------- oBoard of Health Permit No BHP -2010-0611 North Andover P.I. FEE cwF.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd_B-ateson --------------------------------------------------------------------------------------------------- to (Repair -DISTRIBUTION BOX ONLY) an Individual Sewage Disposal System. at No 91 CROSSBOW LANE as shown on the application for Disposal Works Construction Permit No. BHP -2010-061 Dated --- June -02-,-2010 -------- - Issued 0 cliLzi ----------------n: Jun-02-2010 a*�"° "T" �tiCommonwealth of Massachusetts Map -Block -Lot 106.60207 Board of Health ----------------------- • North Andover �•„��.� "5 CERTIFICATE OF COMPLIANCE �SaicNus�i THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -DISTRIBUTION BOX by _,'_Todd Bateson Installer at No CROSSBOW LANE -91--------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. _BHP -2010-061 Dated --- June_ 02,- 2010_ _ _ _ _ _ _ _ ------------------ - - - ------------------------------------ Printe'd On: Jun -15-2010 Board of Health NORTw, 1,. « J 5056 0 - 9 Town of North Andover .�;SS �4'' HEALTH DEPARTMENT SCHU CHECK #: DATE: LOCATION: %vL H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approvalk&wo $ L�J�Septic Disposal Works Co$�� ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer j, - i 4,—j—la TODAY'S DATE $ 250.00 Full Repair $125.00 - Component Important: Application is hereby made for a permit to: When filling out - El Construct a new on-site sewage disposal system* forms on the computer, use❑ Repai r replace an existing on-site sewage disposal system* only, the tab key to move your pair or replace an existing system component - What? —Es 0 k cursor - do not use the return key. A. Facility Information IL—moi Address or Lot # i Cityrrown md - Zbj!�tOE:PARTMEoT 010 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump &travity (choose one) JaIBOy� ***I ump system, attach copy of electrical permit to applic Conventional System (pipe and stones system) Y ) ❑ 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 I T,/ — /fid//e r�t�✓ Name %' � Goss �,.,, L.a.• Address (if different from above) CityfTown .3. Installer Information eAv Name Address A_"g '4A I4 Cityrrown 4. Cityrrown e t r Lla'— State 1p Code Telephone Number BATESON ENTERPRISES Name of Company ROAD AIA 0181 o State Zip Code Telephone Number (Cell Phone # rf possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Dial System Construction Permit • Page t of 2 A-1 7 SEPTIC SYSTEM. INSTALL R PROJECT MANAGEMENT OBLIGATIONS As the North Andover: licensed ;installer for the ,construction. f9r the septic system for the property at: (Address of -septic system) For plans by Relative to theapplication of-1��d✓ (Installer's name) Dated I IocTay s ate (Engineer) And dated ngina date). With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am .obligated to obtain. all permits and Board of Health approved plans or to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I_must call for any and allinspections. If homeowner, contractor. T)roj other person not associated with my coect manager, or any mpany schedules an inspection and the system is not ready, then item three shall. be. applicable. 3.As the installer,: I am required to, have .the.necessary work completed priot to the .applicable inspections as indicated below.I understand that requesting'an inspection without completion:.of the.irPrnc ;,, a, „r;a,;,, by -company.. a.. `Bottom of BM �-Generally, this: is the first (15) in'spectiori unless..,there is a retaining wall, which should be done:first The installer must request the inspection but does not have to be present.'-. b. Final. Construeti ri Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healtlidetowndhorthatidoVer com). from the engineer must be submitted to the Board of Health, after which installer. calls for an inspection time. Installer must be present for this,inspection,. U(lith a pump system, all electrical work:.must be ready and, able to cause ,pump to work and alarm to function. c. :Final Grade —Installer must request 'inspection when all grading is complete. Installer does not have to be on=site. 4. As the installer, I understand that only I Inay perforin the work (other than :simple excavation) and I am required to complete the installation of the system identified in .the attached application for ihstallation:::I . understand: that work done b others unlicensed to install se tics stems .in Nortli.Andover can constitute reasons for denial of the system and/or;':-ocationA"rlAin_or sus 'ension of my license to Mnrtoverate ui. the Town of 1 G �1,,.�ivoivea. a also ossible. 5. As the installer; T understand that I .must be on-site during the.performance of the following construction steps: a. Defetmination that the proper elevation of the excavatiorn has been reached. A Inspection of the sand and sto'e to be used. C. Finalrnspection by Board ofHealth staffor consultant. d. Installation. of tank,D-Box; pipes, stone, vent,. pump chamber, retau components. lirrg wall and other G. TRANSMISSION VERIFICATION REPORT TIME 06/0412010 16:52 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE DIME 06104 16:51 FAX NO./NAME 9784755451 DURATION 00:01:30 PAGE{S} 06 RESULT OK MODE STANDARD ECM s/ Ap►pllca l'on for Septic disposal yste M �— i� Construction Permit — TOWN OF r ; PAGE 2OF2 A. Facility, Informatior continued..,; 5. Type'of Bu'r.lding; e$idential Dwelling or ❑Commerciai TODAY'S DATE $.250.00 - Full Repair $125.00 - Component B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal s tem in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposbl Regulations for the Town of I North Andover, and not to 01ace the system in operation until a Certificate of Compllahce has been lssuepW this Board bf Health. bite ved By: (8 ,Iard of Health Representative) Date D16' approved for the following reasons For Office UseQnly: 1 .Fee -, ftaclird? 1 )Vo 2. .AMIy CtMabager O&liption Pot= Attacheda Yes �+r_� • � ,�°;T ANS ApOlication for Septic Disposal Svstem F ~ , 9 Construction Permit - TOWN. OF TODAY'S DATE ORT14 AND OVER, . MA 01845 $ 250.00 -Full. Repair �'9Ss„CHUS <� $125.00 - Component PAGE 2OF2 Z A. Faciit .Information continued.... y 5. Type of Building:esidential 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 this Board of Health. Na Date Applicatiot)/�Oproved By: (B' and of Health Representative) Date Name Disapproved for the following reasons: For Office Use Only: 1 Fee Attached. Yes Z/ No ` — 2. Project Manager Obligation Form Attached. Yes// No I P!Svstem.? Ifso; Attach copv ofElectrical Permit 4. Foundation As -Built. (new construction ronly); (Same scale as approved plan) 5. Floor Plans? (new construction only); I Yes No Application for Disposal System Construction Permit • Page 2 of 2 7 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. _Q ISI Commonwealth of Massachusetts 1 R Title 5 Official Inspection Form ��;� ��2010 Subsurface Sewage Disposal System Form - Not for Voluntary Asses erI TOWN OF NORTH ANDOVER 91 Crossbow Lane I HEALTH f=1FPAPrA4r-A,T Property Address Leslie Holloran Owner's Name North Andover MA 01845 6/5/2010 Citylrown 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 J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 City/rown 978-475-4786 Telephone Number B. Certification State SI15 License Number Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ° 6/5/2010 Inspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 09/08 Title 5 /Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Crossbow Lane Property Address Leslie Holloran Owner's Name North Andover MA 01845 6/5/2010 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 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: After permit from B.O.H., install new d -box, inspection from B.O.H., septic system now passes Title 5 Inspection 13) 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 ❑ N ❑ ND (Explain below): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 i L4 Commonwealth of Massachusetts ow"o a Title 5 Official Inspection For - - Subsurface Sewage Disposal System Form - Not for Voluntary Asse smeie a 91 Crossbow Lane MAY 2 a 2010 Property Address Leslie Holloran TOWN OF NORTH ANDOVER Owner Owner's Name information is North Andover MA 01845 5/20/2010 required for every page. City/Town State Zip Code Date of Inspection Important: When filling out, forms on the computer, use only the tab key, to move your cursor - do not use the return key. ICS 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 C' T'-.- 1. . 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityfrown 978-475-4786 Telephone Number B. Certification Ma State SI15 License Number L on^—Y l �-1•-�. �.�:5 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Need urther Evaluation by the Local Approving Authority 5/25/2010 Insp t is S nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Crossbow Lane Property Address Leslie Holloran Owner Owners Name information is required for North Andover MA 01845 5/20/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ 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 ® N ❑ ND (Explain below): t5ins • 09/08 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 91 Crossbow Lane Property Address Leslie Holloran Owner Owner's Name information is required for North Andover every page. Cityrrown B. Certification (cont.) t5ins - 09/08 MA 01845 State Zip Code 5/20/2010 Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Crossbow Lane Property Address Leslie Holloran Owner's Name North Andover MA 01845 5/20/2010 Cityfrown 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D -Box needs to be replaced. 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 effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins - 09/08 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 91 Crossbow Lane Property Address Leslie Holloran Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the, last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. ❑ ® 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. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 91 Crossbow Lane Property Address Leslie Holloran Owner Owners Name information is required for North Andover every page. Cityfrown C. Checklist RAA 01845 Zip Code 5/20/2010 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? ® ❑ 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 15ins • 09/06 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 91 Crossbow Lane Property Address Leslie Holloran Owner information is required for every page. t5ins - 09/08 Owner's Name North Andover Cityrrown D. System Information Description: MA 01845 State Zip Code 5/20/2010 Date of Inspection Number of current residents: 4 Does residence have a garbage grinder? ® 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 years usage (gpd)): 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): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 91 Crossbow Lane Owner information is required for every page. Property Address Leslie Holloran Uwners Name North Andover Cityrrown O D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2009, owner 1500 gallons Measured tank Inspect tank & tees 5/20/2010 Date of Inspection ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Crossbow Lane Owner information is required for every page. t5ins • 09/08 Property Address Leslie Holloran Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code 5/20/2010 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Tank installed in 2000, d -box & field installed 5/7/1982, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 2 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" PVC out to septic tank Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass feet ❑ Yes ® No ❑ 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: 6" ❑ Yes ❑ No Title 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 wM 91 Crossbow Lane Property Address Leslie Holloran Owner Owner's Name information is required for North Andover MA 01845 every page. City(rown State Zip Code 5/20/2010 Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 13" 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.): t5ins • 09/08 Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of 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: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 91 Crossbow Lane Property Address Leslie Holloran Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 every page. j Citylrown 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 El other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level:, Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts lug, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Crossbow Lane Owner information is required for every page. Property Address Leslie Holloran Owner's Name North Andover MA 01845 5/20/2010 CityfTown 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 has bad corrosion . Needs to be replaced. Evidence of leakage. 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Crossbow Lane Owner information is required for every page. t5ins . 09/08 Property Address Leslie Holloran Owner's Name North Andover City/Town D. System Information (cont.) Type: MA 01845 State Zip Code 5/20/2010 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 field 20'x 45' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, vegetation, etc.): level of ponding, damp soil, condition of 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 01 r..mcchnw I ane MA 01845 State Zip Code 5/20/2010 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, etc.): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 vroperry Hatuess Leslie Holloran Owner Owner's Name information is North Andover required for every page. City/Town MA 01845 State Zip Code 5/20/2010 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, etc.): t5ins - 09/08 Title 5 Official Inspection Form: 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. 91 Crossbow Lane Leslie Holloran Owner information is required for every page. Owner's Name North Andover CitylTown MA 01845 State Zip Code 5/20/2010 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 r3ference 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 A7 o t� -rCLA O E' =CIOL /4-A-0 1 gQ t 0 C)>- 53 t5ins • 09/08 Title 5 Official Inspection Foran: Subsurface Sewage Disposal System •Page 15 of 17 Owner information is required for every page. 1 11 1*JJVGL1U9i rut -in Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Crossbow Lane Property Aooress Leslie Holloran Owner's Name North Andover MA 01845 5/20/2010 cltyi i own State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ,Z 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: 5/26/1983 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: I Original plans Cl Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•''t 91 Crossbow Lane Owner information is required for every page. Property Address Leslie Holloran Owner's Name North Andover MA 01845 5/20/2010 City/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 file t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 5/14/2010 3:01:59 PM by Karen Hanlon Town of North Andover Class 101 Single Family Size Total 1.01 Acres FY 2010 UB Mailina Index Name/Addrest HOLLORAN, MARTY & LESLIE 91 CROSSBOW LANE N. ANDOVER, 'MA 01845 UB Account Maint. Account No Cycle Bldg Id. 1757610 - 91 CROSSBOW LANE 3170246 03 Cycle 03 UB Services Maint. Account No. 3170246 Service Code MISCFEE ADMIN FEE WTR WATER' UB Meter Maintenance Account No. 3170246 Serial No I Status 36388119 a Active Date 3/10/2010 1/16/2010 1/16/2010 12/10/2009 9/10/2009 6/9/2009 3/13/2009 12/9/2008 9/10/200,8 6/5/2008 3/11/2008 12/10/2007 9/5/2007 6/18/2007 3/15/2007 12/12/2006 9/12/2006 6/19/2006 3/8/2006 Trouble Code:03 12/22/2005 9/21/2005 Trouble Code:O 6/27/2005 3/23/2005 12/13/2004 Tax Map # 210-106.B-0207-0000.0 Parcel Id 17602 91 CROSSBOW LANE HOLLORAN, MARTY & LESLIE 91 CROSSBOW LANE N. ANDOVER, MA 01845 Property Type Type Loan Number Active/Inact. Payor From Occupant Name Active/Inactive Last Billing Date 4/2/2010 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 76.00 /1 3 Location Brand Type ERT HH b Badger w Water Reading Code Consumption Posted Date 12 a Actual 12 4/14/2010 0 n New Meter 0 4/14/2010 5180 r Replacement 8 4/14/2010 5172 a Actual 44 1/12/2010 5128 a Actual 196 10/15/2009 4932 a Actual 163 7/20/2009 4769 a Actual 21 4/29/2009 4748 a Actual 51 1/20/2009 4697 a Actual 211 10/10/2008 4486 a Actual 44 7/16/2008 4442 a Actual 24 4/11/2008 4418 a Actual 89 1/22/2008 4329 a Actual 177 10/12/2007 4152 a Actual 90 7/20/2007 4062 m Manual estimate 20 4/16/2007 4042 a Actual 75 1/19/2007 3967 a Actual 116 10/20/2006 3851 a Actual 113 7/10/2006 3738 a Actual 17 4/17/2006 3721 a Actual 27 1/17/2006 3694 a Actual 46 10/14/2005 3648 a Actual 39 7/15/2005 3609 a Actual 28 4/5/2005 3581 a Actual 68 1/14/2005 Size 0.63 0.63 Page 1 1 Residential Until YTD Cons 8 Variance -100% -100% -55% -77% 14% 729% -61% -74% 325% 96% -72% -59% 136% 341% -74% -40% 24% 390% -24% -45% 32% 45% -67% -48% CN-' Commonwealth of Massachusetts 4 City/Town of a° System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of hous , ight side of ho �, Left front of house, Right front of house, Left rear of house, Right rear of house. a rear of building. Right rear of building. Address (q 1 GNU Cex . e--. City/Towh State 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ k.tW4A-1 � Zip Code State Kip Code Telephone Number Date 2. Quantity Pumped Cesspools)eptic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: L Lowell Waste Water Of Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:4112ql?a CURRENT INSTALLER'S LICENSE# LOCATION: Q/ �pJsiaW LICENSED INSTALLER: / j��I' ocze° ✓Z 'p, SIGNATURE• TELEPHONE# CHECK ONE: REPAIR:y NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes ✓�T No Foundation As -Built? Yes No Floor Plans? Yes No Approval i i i Date: �,a FORM U - LOT RELEASE FORM t-� INS ,T'RUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. .,�..«.«►****«*«.,►,,►««,�*APPLICANT FILLS OUT THIS SECTION* APPLICANT 3ASd,til Gyfb+2D. /2,Q 2! oDC�iPHONE.5O�—. LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET CROSC car•ST, NUMBER USE RECOMMENDATIONS OF TOWN N AGENTS: %� / Il I e rI �I' ATION ADMINIJTRATOR COMMENTS DATE APPROVED DATE REJECTED d -,J- (/J/ Imo_ TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INS��f OR -HEALTH DATE APPROVED / /% DATE REJECTED T,I -INSPEaZJOaR-HEALTH COMMENT'S DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERJWATER CONNECTIONS DRJVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE ■Y" sL —mVW' d J rJS 71Nd13LLd3S:0 NOLLd00l M3N (BWdOad e %1,1 WWII I I i ivim yr acr I iti I tv 115 t NORT)l 4, o � F p ,SSACNUS�S Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 rlr" l -2 19 9 DISPOSAL WORKS CONSTRUCTION PERMIT INSTRUCTIONS: This form is used to verify that all necessary approvals/perl'nitS from Boards and !,-partments having jurisdiction have been obtained. This does not relieve 'the applicant and/or landowner from compliance with any applicable or requiremnts, "'APPLICANT FILLS OUT THIS SECTION l ,1 APPLICANT / s s l(-✓�✓�r.� , .. , _. „/LOCATION: Assessors Map Number SUBDIVISION c WREET "OFFICIAL USE ONLY REC nMENp DA(TI/ONn S OF TOWN AGENTS: AT10N ADMINISTRATOR DATE APPROVED DATE REJECTED PHONE 00.:7 PARCEL LOT (S) ST. NUMBER, I V I to �.s f too TOWN PLANNER DATE APPROVED DATE REJECTED i COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED i C cnr COMMENTS DATE APPROVED DATE REJECTED x /!� 2�� -/) PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT IRE DEPARTMENT -At/�il RECEIVED BY BUILDING INSPECTOR DATE P-4 C) tmj 1-4Z z 0 ii z o o to ED CP CA cD to to CAD P.- Cil 01 0 al o al En tmi w rn m x z z CJI z -D X 0 m;o 0 0 0 0 m (1) > > 0p 00 z z r- m rri x >V) 0 =j z NOIDG(TV m Fn 3 dO8d < 0 -0 co rri ?5 0 0 r- 0 X (n M3MG ONI-LS' rri OZ ............. ............ ............... II N 0 ............... 00 3: m K (A b .......... (,n 0 z ai 0 z (n -u M;u 00 =1T OgSsp�a00 o> Z r -0 00 ri 11% 0 >r 0 > > 0 r z 17 0 z -a a Z -0 cr 'a W ti Cl) 0 1 05. ;j -0 0 co CD CD CD CD W < (D 0 n 0 X, CD CD > 0 C: 3 (D F < 3 Co CO =r CD (1) Q --a 0 :7 CD 0 =3 ::3 Z 02 o 8 m 0 < Q (D 0 -I qL a D CL 0 --+,,-+-0 ., Ul U m ca fa w 3 c a 0 m W 0-0 !Z- z W A 0 Co 0 0 CD =3 -0 a,+- CD c CD o o cr CO S8 t:J J --3 0 z -1 CD CL 0 a- W CD :3 C: 0 0 - 0.0 3 -Q 0 Z CD g8 NE210 -0 0 P - =r M a f, --h 0 CD CD 3 m CD 0 z I'd = co :3 CD cn a CD Z < CD 0 0 CD CD CD 0 w 2 1 0 CD :r 0 <. L 0 0 a C m 2 -< -2 �om 0 0 :3 0 3 co I.I.--3 0 " 0 0 m :P. c-4 no co cn 0 -+, 0 =Y- 0 =3 3:3 I 0 I z 0-(o o C -L m ca 0 > ( llz- -0 0 Q co 00 wm rnCD CDD CD :3 =3 Ch 0 CD 0 tz, ?z CO CD 04/06/98 11:00 '&617 491 0777 BDG INC. CLff LMOFSPAAtK1VE 4WFWANDCOW PIEtt PD®DI MMFEMMSUPPONT MAMNBFORSPAABF.ONE rCOW WALL NBASFYOD. i` tl rMMMLOVERMOM M PAOORiIiTYR ---- --- --- C/) X1002 LOGTIWiSEP 7AW AIiOUrIDIAfIKiPAti9. PtDCMMLATRMPANEUNM 3Uf VOID S' AWA FROM OF" 4'X4' POSTBRXWMOtWW TOOMCFEIEStlPPO FERTYP. l.f"irl ` :f'i: :� � MTMI[K71MIf aCfl11C i A i zo OMCFOOT§fQBBM FRDVMFBISIA mmm CL CD Z i I-- I W 1 i PROPOSED NEW LOCATION bF SEPTIC TANK SM TANK 04/06/98 11:00 e617 491 0777 BDG INC. F" co ~ Y w C v v H 40 V1 c CL co � CD CL a o �� c COL co •� ,� CL •� a [it 003 04/06/98 10:59 ^&617 491 0777 BDG INC. 9001 Baker Design Group, Inc. 435 Washington Street Fax Transmittal Somerville, MA 02143 617 491-0777 Fax 617 491 7007 To Susan Ford 978-688-9540 Kevin Smith 6 April 1998 Project Holloran Residence 978028.00 Number of pages Original will not be sent separately including transmittal 3 Dear Russ For your review and comment, enclosed please find a plan of the Holloran Site & Basement Plan at 1/16"=1'-0" & Holloran Site & Basement Plan at 1/8"=1'-0" showing deck and sono tube locations in relation to the existing location of the septic tank and the new proposed location. Thank You. Kevin Smith N NEW ENGLAND ENGINEERING SERVICES INC Attn: Sandra Starr North Andover Board of Health Town Hall North Andover, Ma. 01845 Re:91 Crossbow Ln. Dear Sandy: July 21, 1995 Please accept this letter as a report of what was done to repair the distribution box problems at the above referenced address. First, A test pit was dug alongside the septic system to examine the condition of the stone in the bed. This was done with a small rubber tire backhoe with both myself and you present. As a result of this inspection it was determined that the bed and the stone were in good condition and the problem with effluent over the inverts of the d -box inverts must be related to another problem. Next, the distribution box and piping leading to the bed was uncovered in full to determine how these components existed in the ground. Upon surveying with a transit the elevations of each pipe as it exited the distribution box, and comparing those elevations with the elevations of the pipes as they entered the leach field, it was discovered that all of the pipes were higher at the field than in the box. The difference in elevation ranged from a difference of one hundredth to six hundredths of a foot. In addition some of the pipes were crowned upward two or three hundredths. The final step in making the repair was to raise the distribution box one hundredth of a foot. This was done and you inspected this work and said it was acceptable. Accordingly, I have enclosed a revised sheet 12 and sheet 13 that should be attached to the original report along with this letter as an addendum to my original report. The new sheet certifies that the system passes the title 5 inspection. 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 NEW ENGLAND ENGINEERING SERVICES INC If you have any questions please do not hesitate to call. Yours Truly Benjafiin C. Osgoo Jr. enclosures cc:Paul Powers 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 z I T i- 7 p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property GJ j F<.<�s; L_n/,, n; . 61 i.. ,(; f? ,1n r} Owner's name Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of He lth. ✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /v1"' As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. % The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, -material of construction, dimensions,. depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non -intrusive methods. ✓� The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT! PART B SYSTEM INFORMATION FLOW CONDITIONS If residential -3.,.., number of bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: (2,,r rP✓,+ Last date of occupancy; GENERAL INFORMATION Pumping records and source of information: V �.. System pumped as part. of .inspection, yes or no if yes, volume pumped Reason for pumping: yppS,If, system eptic tank/distribution box/soil absorption system Single cesspool overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART E SYSTEM INFORMATION continued SEPTIC TA. iX: _ (:locate on site plan) depth below grade: material of construction: v� concrete metal FRP other(explain) dimensions: L 'X ,:. xs sludge depth distance from top of sludge to bottom of outlet tee or baffle 1` scum thickness R'' distance from top of scum to top of outlet tee or baffle th" distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation.for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) Tc*G'S S .�ti,r? �'�/3� G Z:;S c:; i/.. -7 DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Commentsi (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of boa, recommendation for repairs, etc.) PUMP CHAMBER: .(Locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION" SYSTEM (SAS):_ (locatelon site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type I leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number —1 F,<c.=L0 20�- sem. Comments': (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations fo� maintenance or repairs,etc.) rq - P`(�HA/f-T i T IS G.J cr2 10ESSPOOLS (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 (cesspool must be pumped as part of jinspection) Comments: .(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repai,rs,etc.). .......... PRIVY: (locate o?, site plan) materials of construction dimensions depth of solids T Comments: (note condition of soil, signs of hydraulic failure, level of ponding, corditioniof vegetation, recommendations for maintenance or repairs,etc.) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION" SYSTEM (SAS):_ (locatelon site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type I leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number —1 F,<c.=L0 20�- sem. Comments': (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations fo� maintenance or repairs,etc.) rq - P`(�HA/f-T i T IS G.J cr2 10ESSPOOLS (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 (cesspool must be pumped as part of jinspection) Comments: .(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repai,rs,etc.). .......... PRIVY: (locate o?, site plan) materials of construction dimensions depth of solids T Comments: (note condition of soil, signs of hydraulic failure, level of ponding, corditioniof vegetation, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: L0 ncrAL:-or el t= r+ 11 W 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) yw Backup of sewage into facility? _�✓� Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liauid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial ex -filtration? tank failure imminent? Is any portion of the SAS, cesspool or privy: 2_. below the high groundwater elevation? within 50 feet of a surface water? 1 within.100 feet of a surface water.supply or tributary to a surface water supply? within a Zone I of a public well? A/ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, ncu the SAS)? within 50 feet of a private water supply well? A/1Iess than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well h.as been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector „A;.�. c�S , �. n .s -'t, Company Name ti CFk, e ,./ e_ -i- i4 0 <r i n. c' cc ,2 Company Address 13 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails toI adequately.protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. _,Z I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature I Date Original to system owner Copies to: Buyer (if applicable) Approving authority Tl^1S s Sir- �'fr%kYli�ci�L, f cni�� t ' I P i rL> E �' r' 0. ,fl- s fx.>T G i 1' t: ✓> I Oct 3`X / Al 3 iil:IA L �- a 19 U L Z. ..!3 ''. '4Q 9100 Soo G-,9 -1. (44 Fj 5 /"=4c' it=46) Board of Health - North Anoover�, ass. SEPTIC S�� LIST • INSTA=TIC6 CDISUPROM 1. Distance Tot a. Wetlands b. Drains Co. Well 2. Water Line Location LOT"j % 3. No PVC Pipe %. Septic Tank a. _Tess --Length & To Clean Out Covers.. - b. Cement Pipe to Tank Ca Both Sides of Tank 5. Distribution Boa a. Covers & Box - No Cracks b. All Lines Flo Amg Equal- Awimts c. No Back Flow .A b. Leach Field or Trench a. Dimensions b�. Stone - Depth - ' - -- --- - - - - - - __ c. Capped Rid a. Clean Double Washed Stone 7 " Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees - e. Cement Pipe to Pitr - Both -Sides f. Clean Double .Washed Stone 8. No Garbage -Disposal -_._. 9. 11na7 Grading -Inspection lO. _ Barricading Covered System 11. As Built Submi-tted _ 'a. Lot Location _ - _ = b. -Dimensions of -System- _ = c. Location -.4th Regard. -to Perc Test - _ d. Elevations _ e; Water Table. TO: NORTH ANDOVER, MASS BOARD OF HEALTH FROM: DESIGN ENGINEER 19 Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at L -a 8 CkaSS 6 ocu 1-11 jua- North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated —19-6-3— Ly NEVE /� sso�t tEs Board of Health 2:ae0h ,ndover,?iasa f - i . SUBSURFACE DISPOSAL DtSIGN CHECK LIST Title V I FAIL Reg 2.5 0% L LOT C�S� DISAPPROM DATE Reasons: The submitted plan must show as a mdnimtlm: a) the lot to be served -area, dimensions lot #, abutters b location and log deep observation holes -distance to ties location and results percolation tests -distance to ties cd design calculations & calculations shoring required leaching area e) location and dimensions of system -including neserve area T) existing and proposed contours 'j location any vat areas Athin 1001 of sewage disposal system or 4 disclaimer -check wetlands mapping surface and subsurface drains within 100' of sewage disposal stem or disclaimer location any drainage ease.► eats within I001 of serge disposal system or di sclair-er- Planning Board files knoun sources of vater s=ply within 2001 of se,�age disposal e system or discl.ainer location of any proposed well to serve lot -1001 from leaching facili ;'15 location of meter lines on property -101 from leaching facility �m) location of benchmark ;�ive�,•zys ,,o) garbage disposals )) PoPVC to be used in construction �Wprofile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations rr) mayj= m ground pater elevation in area se�.age disposal system ;s) plan nust be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 I Septic Tanks �ra) capacities -150 of flow, meter table, tees, depth of tees, access, Pu --ping cl eanout 101 from cellar -w-all or inground �g Pool 251 from subsurface drains Reg 10.2I Distribution Foxes a s ape greater t'c�an 0.08 Reg 10.1 ) stomp DIe+V e -To• i3E or�' OW 540E GF V*OQC'C i UVA•N SiiFPP-C_. Subsurface Desip Check, I FAIL I Og 2 J. Leaching Pits Leaching pits are preferred where the installation is possible a) calculations of hing area -minimum 500 eq ft b) spacing C) surface ge L d) cover terial e) 21 All splash pad f e at elbow no bends in pipe from d -box to pipe Leaching Fields Reg 15.1 4aa) no greateran 20 minutes/inch area-r-initrm 900 sq ft 15.4 ) construction of field 15.8 ) surface drainage 2 % 3.7 ) 20 from cellar v -,-Il or inground &4nr dng pool Reg 14.1 14.3 14.4 l i.6 14.7 1t..10 Reg 9.1- 9.6 .lg.6 5eag �°r Enches a) a" s o`Tes g air -ren 500 sq ft b) -4 ft ft with reserve bet -ween c) ons d) c e) f) drainage 2I Do Slope a� s op e y x= to be s_ho-vnn) b) y/x x 150 = (to be sho,,n) pu-r,Ds a) amp cal b) ' a-nd-by power SUlL YKUYILr & YEKLAiLA1'lul'i LUi'1'X North Andover, Mass. Street No CIzosg jow Lot No $ to Loc/Subdiv. Pland Owner Investigator S.Z 512-1 8-3 Observer MSR Z) ws I�1 Bd SOIL PROFILE DATES I I So 1_'Elev 2.Elev 3.Elev 4.E1ev S�z� 83 O 6 31 ev 0 T --V o 0 1 1 1 9 l Benchmark Elevation 2 3 4 5 6 7 8 T� S 2 3 4 U 5 3 6 7 8 3 4 Start Saturation 5� pry 9 9 10 to I Location Datum �! PERCOj,ATION TESTS DATES t'" L -7 111 1 Al 1 2 C 4 5 6 7 8 9 10 Timmstc� sTest Pi -/rlo IFeze- 2 - iCl� FSE Pit Number i 2 3 4 Start Saturation Soak -Minutes 5tart Te Drop of 3" -Time Drop of 6" -Time Mmns.lst 3" drop g Mins.2nd " Drop/Z Percolation