HomeMy WebLinkAboutMiscellaneous - 967 JOHNSON STREET 4/30/2018 (2)0 32- 4 Date ... .............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .............
has permission to perform .........
wiring in the building of ............
at .............. .............. -5.7 .............. . North omdoverSuss
Fee..../'?........... Lic. No. . .........
::�-kx ELECTRICAL iWspi(crm
Check #-W
41
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordanee-with the pzov 10ns of M.G.L. c. 143, §. 3L, the
permit application form to provide notice of installation of wiring shallbe uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall be limited as to the time of ongoing construction. activity, and maybe.deemedby-the. inspector_of_Wires abandoned.and-in .aliddfhe—.
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing►entity stated on the permit application.
❑ The Permit ]Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promote job=growth and long-term economic recovery and the Permit Extension Act firthers this
purpose by establishing an automatic four-year extension to certain -permits and licenses concerning the use or development ofreal property. With
limited exceptions, the Act automatically dxtends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the quarrfying period beginning on August 15, 2008 -and extending through August 15, 2012.
Rule 8—Permit/Date Closed: ** Note: Reapply for new perm
❑ Permit Extension Act—Permit/Date Closed:
ti
Comm4Gnu;eA9 o f M"acrliujefb. Of ficial Use Only
—ter cC�� cc77 �7 Permit No. !J 3 -
. CJe�artrnen!` o�. 7`ire Jarviceb
Occupancy and Fee Checked
BOARD OF FIRE PREVENT ION REGULATIONS [Rev. 1/07] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PP1NT IN INK OR TYPE ALL IMFORMATION) Date:
City or Tmyu of: Nrj r jf� I -"1f N exp ue r To the Inspecto of Wires:
By this application. the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 96 7 Ar) 4,USbAJ qrr
Owner -or Tenant M ACJ/'e Telephone No -11 1?fJ
Owner's Address 9 ��� j j T No, A A%6LYeQ #41ig 01 "Y"
Is this permit -in conjunction with a building permit? Yes ❑ No. [ (Check Appropriate Box)
Purpose of Building Utility Authorization .No.
Existing Service __- Amps i Volts Overhead ❑ . Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived b ty he Inyectrr of F ira-.
No. of Recessed Luminaires
-�--
SPaddle) F
No. of Ceil:usp. ( Far -is
No. of - VA
K
Transformers VA
No. of Luminaire Outlets _
INo. of Hot Tubs
Generators KVA
No of Luminaires
I Above in-
Sv!imrring Pool rnd. ❑ arnd. E]
o. of Emergency ig acing r
Battery Units
No. of Receptacle Outlets
INo. of Oil Burners
FIRE ALARMS No. of Zones
No. ofSwvitches _
_
No. of Gas Burners
No. o Detection and
Initiating Deyices
No. of Ranges
Total
`No.. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
-
To_ns
K_W _ _
No, of Self -Contained.
Detection/Alerting Devices
No. of Dishwashers
Space/Asea Heating KW
Local El inn l
p• ❑ Other
.. ctron .
onnaa —
No. of Dryers
Heating Appliances KW
Security. systems:"
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters I
Signs Ballasts
No. of Devices or Equivalent
g
No. Hydromassage Bathtubs
b
No of Motors Total HP
_
Telecommunications 1quiv
No. of Devices or Equivalent _
OTHER:��;
Attach-additicnol detail if desired, or as required by the Inspector of l!'ires.
Estimated Value of Electrical Work: �so,
(When required by municipal policy.)
Work to Start:_5 Inspections to be requested in accordance with MEC Rule 10, and upon. completion.
ce
INSURANCE COVERA E Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides, proof of liability insurance including "completed operation" coverage or its substantial equivalent. the
undersigned certifies that such coverage is in force, and has eyhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:)'
I certify, tinder the pains and penalties ofperjury,-that the in ormation. on this application is true and complete.
FIRM NAME: LIC. NO.: C Z15
Licensee: f r) a Signatu _ LIC. NO.: <2 t �-
(Ifapplicable, enter "Pexem t" in the license mrmberc e l Bus. TeI. No. d 57--q -,i
Address: \ C�-r +'� l tm f. ,-h� 1��5, I� O a0 Alt. Tel. No.:_
"Per NI.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: I.ic. No. D675 B
OWNER'S INS U RANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required bylaw. By my signature below.;-! hereby vraivT this requirement. I am the (check one) ❑ owner Q owner's a ent.
Owner/Agent 1, Ops
Sigr_ature Telephone No. PER/Y'I7 FEE:
J
n 1 � = '
"=A;RE.G ISTERED SYSTEM CONI RAC OP....::`
lSSUESTNEABOVELICENScTO: -
DT SECURIT-Y,S_ERVICES,:.ING
: BROPHY:= SR
•10i1tt1IVERSIiY.'AVE
-,;FiESTklQOD MA':•0209.D-2313.";i;-.,
C 07/31/13 :849174':.'.:
f:. ' r: •' - Fob.7Tan Oalnrtl Atm¢Ae P]LOmGcns -
Keep top for receipt and change
OpS_CA1 i� 351,4-10109-10162009LICENSEFORMI
✓�zc T.o>•�:nico�rurea.`i�• c� il/iaka�ic.:eC�s
- DEPARTMENT OF PUBLIC SAFETY
! S :License
Numbec' SS CO 000953
Expires: 0?JOT12013 Tr. no: 195.0
S -License: ADT
MARK A BROPHY. SR
410 UNIVERSITY AVEG1 �/J��— DIG SAFE CALL CENTER: (888) 344-7233
WESiWOOD, tv1A 02090 Commissioner
��
GREATER LAWRENCE SANITARY DISTRICT
CHARLES STREET, NORTH ANDOVER, MASS. 01845
TRUCKED WASTEWATER DISCHARGE SLIP
"I 190VA9°VPrC '' ate. , fr��� � Slip No.
TOWN
Company Name:°Z ~ �� a Date:
Hauler's Name:
Address: / • d.
Telephone: / y yY' 41/ y 019
SOURCE #1 Date Pumped: -.3
Name: 1,194,y re o Tank Size: o o
Address: 9&0
0
Telephone:' < A,
Signature:.
SOURCE #2 Date Pumped: 1' 4 .,?
Name: %�'� H , Tank Size:
Address:
Telephone:;;/` / f
Signature:
SOURCE #3 Date Pumped:
Name: Tank Size: 4
Address: /Y
Telephone:
Signature:
To the best of my knowledge the above information is true and correct.
Hauler's Signature
7
Tank Size: 3,� ° b
r
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
v
SYS
ADD
%Pik c C' o
(a �eh�ns a.► S +
Or a "EM LOCATION
(example: left front of house)
DATE OF PUMPING: '/,�' c QUANTITY PLrMpED /o o v
GALLONS
CESSPOOL: NO / YES SEPTIC TANK: NO
,_� YES
NATURE OF SERVICE: ROUTINE �-i
EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE FULL TO COVER
ROOTS BAFFLES IN PLACE
EXCESSIVE SOLIDS LEACHFIELD RUNBACK
SOLIDS CARRYOVERFLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Jo X,,O Z-A,VAJ,� O.
COMMENTS:
CONTENTS TRANSFERRED TO: g l
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 3�
ADD
A, J-&�-s �
,q6tj a s
(example: left front of house)
DATE OF PUMPING: 3
QUANTITY PUMPED GALLONS
CESSPOOL: NO - YES SEPTIC TANK: NO YES'
NATURE OF SERVICE: ROUTINE ( EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
NONE m4y, W-A-M.Evall
CONTENTS TRANSFERRED TO: C (, �^
A
t VCYo- Z-:Lzassacliusetts
sachusetts
System Pumping Record
System Owner
Date of Pumping:
tu., 3— q
Cesspool: No Yes U
System Location
q6`7 �
�+
Quantity Pumped: CCI gallons
Septic Tank: No �_� Yes �'—
System Pumped by: g4eed4lC 5114e'44aa License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector:
Board of Health SEPTIC SISTEK
North AndoverZHaaa.
' INSTA?•LATICK CHECK LIST
0—ED— DATE DI SAPPi�03ED
ea aons t.
JC7`lC�'
LOT ` I l JOMSO&J
AVATICN OK PAIL
OK
1.
Distance To:
a. Wetlands
b.. Drains,
r�
c... Well
10-9 4
2.
Water Line Location'
3.
F
No PVC Pipe
4.
Septic Tank
a. Tees w --Length '& To Clew Out Covers
b. Cement Pipe to Tank -On Both Sides of Tank
5.
Distribution Box
a. Covers & Box - No Cracks
b. All Lines. Flowing Equal Amounts
c. No Back Flow
6.
Leach Field or Trench
a. Dimensions
b. Stone °De ith
c. Capped Ends
d. Clean Double Washed Stone
7.
Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Teas
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8.
No Garbage Disposal
9.
yinal Grading Inspection
10.
Barricading Covered System
\Ol
Olt
11.
As Built Submitted
a. Lot Location
u -
_
b. Dimensions of System
C. Location with Regard -to Perc Test
d. Elevations
e. Water Table
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845 TEL. 682-6400
May 31,1984
TO WHOM IT MAY CONCERN
Upon deep hole tests done
3/27/84 on Lot 11 Johnson St. the owner may lower
the bottom of pit elevation to 210.0 which is
approximately 5 feet below the original design
by Flynn Associates dated 10/27/83. System may
be moved to the left side of lot in the location
of the deep hole. No additonal plans will be
needed as discuss with Engineer Al Shaboo on
3/28/84. Plan in file is marl-
suggested changes inition by i
Michael J. Rosati, R.S.
SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street' No otatJ SON ST . Lot No
4-19
Loc/Subdiv. Pland Owner
InvestigatorObserver
SOIL PROFILE DATES
l.'Elev 2.Elev 3.Elev 4.Elev
1 '1 5
5 —►y D
w'STO,v s
I ►Ju w&
Benchmark
Elevation
0
1
2
3
4
5
6
7
8
9
10
0
1
2
.3
4
5
6
7
8
9
10
Location
Datum
PERCOLATION TESTS
DATES L I c,( BS 41 U wz.
1
n
Tiles p sTest f
Pit Number
2 3 43
Start Saturation
Soak -Minutes
L
Start e
Drop of 3" -Time
2- Z
Drop of 6" -Time
Mmms-lst 3" drop
_
Mins.2nd 311 Drop`
"' �f��t.�•
ercolation�,�
�-
JCuk�JSq� `'T
w�
�5�� 1J`i
1 �
w� i S Z
&3oarr;J of Health
!icr*wh :.ndoversMass
'
SUBm'FACE DISPOSAL DFSICR% CF g LIST
LOT # i1i1�w��N►
.
APPROVED DATE
DISAPPROVED DATE
Provided:
- -
Reasons:
866V 1003 �o fNC�`J
X93
Title V
FAIL
Reg 2.5
e submitted plan trust sbow as a minimum:
dim ensions lot #,abutters
the lot to be served -areas
holes-distxnce to ties
b
location and log deep observation
location and results percolation tests -distance to ties
design calculations & calculations shoring rawired leaching area
location and dimensions of system -including reserve area
(g)
existing and proposed contours
'cation any vat axaas -.thin 1001 of se -,age disposal system or
h
disclaimer -check wetlands napping
ms within 100' of swage disposal
surface and subsurface drains e
(i)
system or disclaimer
location any drainage easements within 100' of se-csge disposal
system or disclairyr-Pla--I.ning Board files
sores of water s=ply wij�n 2001 of sewage disposal e1-10 _
(k
system or disclainer
ocation of any proposed :-ell to serve lot -100 from leaching facili
location of water Lines on proper ty-10 1 from leaching facility
location of benchmark
n
arive�,zys
o
garbage disposals
q
PVC to be used in construction
profile of syste-m-elutions of basements plumbs pipe, septic - tank.,
—�!
distribution box inlets and outlets, distribution field piping and
}
Otler elevations
maYi m m ground- water- elevation in area sewage disposal system
L, --s)
plan toast be prepared by a Professional Bbgineer or other
professional authorized by 1au to prepare such plants
Reg 6
a)
Septic Tanks
capacities -150 of flogs -water table, teess depth of tees,
accesss ping
-00
A)
cleanout
10' from cellar --all or i aground sw�.-.ng pool
(d)
251 from subsurface dr& ns
Reg 10.2 I
Distribution Foxes
(-) s ope greater than 0.08
Reg 10.4 ( b) inuip
Subt zr.'ace Desi
I FAn
Reg 15.1
15.4
15.8
3.7
Reg 14.1
14.3
x-4.4
31,.6
14.7
.10
Reg 9.1
9.6
+Check'ILiat
I � I
Leaching Pits
7
Leaching pits Are preferred where the installation is possible
calculations of leaching area -minimum 500 sq ft
spacing
surface drainage 2%
cover material
2' x2 t x4II splash pad
,-) tee at elbow
g) no bends in pipe from d -box to pipe
Leaching Fields
a) no greater ttan minutes/inch
b) area- sq ft
c) construe on of field
d) surf drainage 2 %
e) 20 from cellar Xll or inground s rimming pool
Leaching n Tirorches
a) cc cuUtIons eaching area -min 500 sq ft
b) spacing-lt� rain 6 ft with reserve betueen
c) dim.: ns
d)con ction
e} ane
f} surface drainage 2%
y Da Sloe
41 slop ey x = to be s_hosw:i)
b) y/x X 1503 = (to be shown)
ka-i
a) val
b)d-by power
t��34-19.50�Y
I
LOT 11
44, 49u
+ I CERTIFY THATTHE SEPTIC S1 ; i D l WAS INSTALLEL, AS SHOWN.
THIS PLAN IS NOT IN T ENW:L AS A WA14RMTY OF TPE SYSTRI
t-F�IPERTt GESCRII�Tt:�, �1�;1f.' t;ERG �N"SZ�ao
19.
34' —"
R EVAMONS
TOP rND
219,GG
HOUSE OvTL! ,
217-S4
ST INLET
2IG.X)
S T OUTLET
D•6CjK it4LOr-E
?I. s�
D -Box OJY_t'2i4.70
PTT*I
21317r.
PIT*2
213 �t>
J` X111 1 :tet �1�1�If�i�: v ES- \C SF ER G \�
DISPOS(,L. SyS t E--tJ A� E'UIL.1
Jo
PktPARE G PY--
�L Yi ISI i / ' I�J� J �� �P✓O
1
L/I,/-
s
t
1
A
LOT 11
44, 4t}i�,$
v
W
'o
�N
z
341 —
E.E�,AT,0,
TOP r'Mi 21yo66
t10U:,c 0"1'_ i 217.x+
ST INLET L;r.i'
S T T
C- Flo 11F -2W73
PST `I 21 J. 7F
PI T~2 2 I: t.
0
e
. a.. -1ATiot ��� 1- + ►r
I CERTIFY THATTHE SEPTIC SYSTEM! WAS INSTALLED AS SHOWN.
THIS PIAN IS NOT INTENDED AS A WARRAN-I OF THE SYSTEM
PROPERTY DESCRIPTI;N FROtA NERb'FLANt*9274, L�I �� �' AL I= 4U'
~ PREPAP. D BY— -
�YI`�l\f
j' �?
\J L J
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF I&MAONMENTAL PROTECTION
ONE WI1Q'I'ER STREET, BOSTON MA 02108 (617) 292-5500
ARGEO PAUL CELLUCCI
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEMA WSPECTION FORM
PART A
iEiTIPICATION
Property Address: 967 Johnson Street, North Andover Name of Owner: Peter Manzoni
Address of Owner: 967 Johnson Street
Date of Inspection: 10/211999
Name of Inspector. Neil J. Bateson
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Bateson Enterprises Inc.
Mailing Address: 111 Argilla Road Andover, MA 01810
Telephone Number: ( 978 ) 475-4786
TRUDY COXE
DAVID B. STRUHS
Commissioner
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my.training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
—X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 1 01211 99 9
The System Inspector shallOthesystern
cop of is inspection report to the Approving Authority (Board of Health or DEP)wfthin thirty (30) days of
completing this inspection. Iis hared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
4 1339
revised 9/2/98 Page I of 11—
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 967 Johnson Street, North Andover
Owner: Manzoni
Date of inspection: 10/2/1999
INSPECTION SUMMARY: Check A, A C, or D:
A. SYSTEM PASSES:
_X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or move system components as described in the'Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 912198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 967 Johnson Street, North Andover
Owner: Manzoni
Date of Inspection: 10/211999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT
THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water.
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 912198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 967 Johnson Street, North Andover
Owner. Manzoni
Date of Inspection: 10/2/1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less -than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile
organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS -
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area @ IWPA) or a mapped Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 967 Johnson Street, Noth Andover
Owner. Manzoni
Date of Inspection: 10/2/1999
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_X Pumping information was provided by the owner, occupant, or Board of Health.
X 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.
_X _ As built plans have been obtained and examined. Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
_X _ The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout.
X All system components, excluding the Soil Absorption System, have been located on the site.
X_ 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 Soil Absorption System on the site has been determined based on:
_X Existing information. For example, Plan at B.O.H.
X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[I 5.302(3)(b)]
_X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 912198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 967 Johnson Street, North Andover
Owner: Manzoni
Date of Inspection: 1001999
FLOW CONDITIONS
RESIDENTIAL:
Design flow::_150_ .g.p.d./bedroom.
Number of bedrooms (design): 4_ Number of bedrooms (actual): -
4 -Total DESIGN flow _600
Number of current residents: _2,
Garbage grinder (yes or no): _Yes_
Laundry (separate system) (yes or no):—No—; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): No
Water meter readings, if available (last two years usage (gpd): March 97 to April 99 21,200 tt3 x 7.5=159,000Gals. / 730 Days = 217 Gals. / Day
Sump Pump (yes or no): _No_
Last date of occupancy: _Current
COM M ERCIALII N DUSTRIAL:
Type of establishment:
Design flow: gpd( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Non -sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: Pumped two years ago, Owner
System pumped as part of inspection: (yes or no)_Yes_
If yes, volume pumped: _1500_allons
Reason for pumping: Inspect tank, baffle & tees.
TYPE OF SYSTEM
X_ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 15 years, 10/3/84, as built plan.
Sewage odors detected when arriving at the site: (yes or no) -
No -
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 967 Johnson Street, North Andover
Owner: Manzonl
Date of Inspection: 10/2/1999
BUILDING SEWER: X
(Locate on site plan)
Depth below grade: 13"
Material of construction _X cast iron _X 40 PVC _ other (explain)
Distance from private water supply well or suction line:
Diameter: 4"
Comments: 4" cast iron leaving foundation, 3" PVC in house.
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1"
Material of construction: _X concrete _metal Fiberglass _Polyethylene _other (explain)
If tank is metal, list age _Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions: 10' x 5' x 4' X 7.5 = 1500 gallons
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 21"
Scum thickness:
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: 15"
How dimensions were determined: Subtract scum & sludge depths to tee length
Comments: Pumped septic tank. Inlet tee ok. Inlet baffle ok. Inlet pipe doesn't go in to tee. Outlet tee ok. Depth of liquid at outlet invert. No leakage.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 967 Johnson Street, North Andover
Owner: Manzoni
Date of Inspection: 10/2/1999
TIGHT OR HOLDING TANK: _None_ (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete _ metal _Fiberglass Polyethylene _other(explain)
Dimensions:
Capacity:allons
Design flow:_allons/day
Alarm present
Alarm level: Alarm in working order. Yes _ No
Date of previous pumping:
Comments:
DISTRIBUTION BOX.:_X
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments: D -box level & distribution equal. Evidence of solid carryover. Pumped d -box to clean. No evidence of leakage.
PUMP CHAMBER: _None, gravity system_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
Revised 912198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued))
Property Address: 967 Johnson Street, North Andover
Owner. Manzoni
Date of Inspection: 10/2/1999
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods)
If not located, explain:
Type:
leaching pits, number: 2
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Aftemative system:
Name of Technology:
Comments: Soil ok. Vegetation ok. No sign of ponding to surface. Pits # 1 & 2 water 8" from invert. Camera pits by outlet pipes in d -box.
CESSPOOLS: None
(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 inspection)
Comments:
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 967 Johnson Street, North Andover
Owner. Manzoni
Date of Inspection: 1012!1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
•tot=16'8"
•to2= 13'5"
A to D -box = 33'
B to 1 = 31'5"
B to 2 = 387"
B to D -box = 44'5"
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 967 Johnson Street, North Andover
Owner. Manzoni
Date of Inspection: 10/2/1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater > 6 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_X Obtained from Design Plans on record
_X Observed Site (Abutting property, observation hole, basement sump etc.)
—X—Determined from local conditions
—X—Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. Must be completed) Essex county soil map, sheet # 35, canton sal > 6 ft water table.
revised 912198 Page 11 of 11
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 967 Johnson Street, North Andover
Owner: Manzoni
Date of Inspection: 10/2/1999
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bateson
Bateson Enterprises, Inc.