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HomeMy WebLinkAboutMiscellaneous - 97 FOREST STREET 4/30/2018yi J Commonwealth of Massac City/Town of System Pumping Record Form 4 RECEIVE Ul.-_ r 12013 TOWN Or Nijrrt r ri ANDOVER HEALTH DEPARTMENT DEP has provided this form for us&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 fight front of , Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address q P—� City/Town State Zip Code 2. System Owner. Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): statt 14 �/ C_'Ci piRode Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) OlSeptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [![ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 4"4j Q 6. System Pumped By.- Neil y:Neil Bateson 7. Name Bateson EnterDrises Inc Company where contents were disposed: rN...M Waste Water F5821 Vehicle License Number -G, t5form4.doc• 06/03 System Pumping Record •Page 1 of 1 x d d N En 0 LE 0 0 K H d d N En 0 LE 0 0 K H O•'. Q 'o • z g� m H N c� to c� y ro � 0 H Tod O 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 7 Forest Street N.Anclover, MAA6184_5 Owner's Name: Grant & Jane PesIrson Owner's Address: Same Date of Inspection: 0 UT y Name of Inspector: (please print) John J. Soucy Company Name: Soucy' s Sewer Service Inc Milling Address:830 Livingston Street Tewksbury.- MA ,01876 Telephone Number. 928-851 _ ,8839 - �OOp� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Inspector's Signature: X Pan" Conditionally Passes ��Needs Further Evaluation by the Local Approving Authority Date: v n The system inspector shall submea copy of this b4pectioow n to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If thevstem is a shared system or has a design flow of 10,000 gpd or greater, the inspector ad the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes end Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspectiow does not address hpw the system.will perform In the future under the same or different conditions of use.. Title 5 Iaspectibn Form 6/15/2000 page 1 i Page 2 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 Forest Street N. n overt MX U1645 Owner: Cr nt & Jane Pearson Date of lospection: July 1Q, 2002 Inspection Summary: Check A,B,CM or E /ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that say 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: a System conditionally Passes: 'One ormore 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 liealth, will pass. Answer yes, no or not determined (Y,N,ND) in the 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 pxfiltration 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution bcx due to broken or obstructed pipe($) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) aro replaced obswctioa is removed distributicxt box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will Pau inspection if (with approval of the Board of Health): ND explain: broken pipe(s) aro replaced obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:97 Forest Street N.Andov_er, MA 01845 Owner. c_;_an , & .jne Pe^,s on Date of Inspection: Jii I y 1♦2 0 0 2 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. L System will pass unless Board of Health determines in accordance with 310 CMR 15.303(lxb) that the system is not functioning in a manner which will protect public health, safety and the environment: — Cesspool or privy is within 50 feat of a surface water _ Cesspool or privy is within 30 feet of a bordering vegetated wetland or a salol marsh 2. System will fail unless the Hoard 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. — Tie system has a septic tankend SAS and the SAS is less than 100 feet but 50 fect or more from a private water supply wells*. Method used to determine distance ••This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm, provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: 3 Page_4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:97 Forest Street N. Alitluvei , 45 Owner. Grant 9 Jane Date of Iwpectlon: u Y D. System Failure Criteria applicable to all systems: You i1 w indicate "yes" or "40 to each of the following for inspections: Yes No ..._ , Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -- Discharge or Pomftg of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level im the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _. Uquid depth in cesspool is less than 6" below invert or available volute is less than 1/z day flow --- Required pump 14 more than 4 times in the last year EDT 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 So feet from a private water supply well with no"acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen las equal to or less than S ppm, provided that no other failure criteria are triggered. A copy of the analysis must be,attaebed to this form.] (YesJNo) The system lab 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 1000 gpd to 15,000 tied You must indicate either" es" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 dr4wg water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead protection Area — IWPA) or a mapped Zone 1I. 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 systo<ta owner should contact the appropriate regional office of the Department. 2 i P. age. of 11 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE- SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddress• 97 Forest Street �N. An over, 45 Owner:Grant & Jane Pearson Date of Inspection: July 10 , 2 0 0 2 Check if the following have been done You must t es" or "no" as to each of the followine- Yes No XPumping information was provided bythe owner, occupant, or Board of Health X _ ,Were any of the system components pumped out in the previous two weeks ? X _ Has the system received normal flows in the previous two week period ? X _ 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) X _ Was the facility or dwelling inspected for signs of sewage back up ? _ X _ Was the site inspected for signs of break out ? X _ Were all system components, excluding the SAS, located on site ? X 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 ? X — Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no .X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)}: 5 Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE: SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C: SYSTEM INFORMATION Property Address 9.7 Forest. Street N. Andover, 45 Owner: Grant & Jane Pearson . Date of Inspection: Jul y 10 , FLOW CONDI�'IONS RESIDENTIAL Number of bedrooms (design): 4 ' rt Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 4 4 0 Number of current residents: 2 Does residence have a garbage grinder (yes or no): Yes, Recommended removal of unit Is laundry on a separate sewage systetp (yes or no): No [if yes separate inspection required] Laundry system inspected (yes or no): Yes Seasonal use: (yes or no)NCL Water meter readings, if available (last 2 years usage (gpd)): See Attached Sump pump (yes or no): Z. Last date of occupancy:—Curr.t COMMERCIAL/INDUSTRIAL Type of establishment: N /A Design flow (based on 310 CMR 15.203): Rd Basis of design flow (seats/persons/sq%etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): .. GENERAL INFORMATION PumpingRecords Source ofinformatiowevery 2-3 years Was system pumped as part of the inspection (yes or no): , If yes, volume pumped3 5 0 0 gallons How was quantity pumped determined? Reason for pumping;a a i n t- a i n a n r a 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) _ Tight tank , Attach a copy of the DEP approval _ Other (describe): Approximate age of all components, date installed (if known) and source of information: Fifteen Years Were sewage odors detected when arriving at the site (yes or no)No 6 Page 7 of 11 OFFICIAL INSPECTION FORM r NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SMAGEDISPOSAL'SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Property Address: 97 Forest Street N.An over, MA 01845 Owner:Grant & Jane Pearson Date of Inspection: July 10 , 2 0 0 2 BUILDING SEWER (locate onsite plan) Depth below gradel 8 Materials of construction:Xcast iron !-21'40 PVC _other (explain): Distance from private water supply well or suction line: N /A Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ (locate on site plan) Depth below grade: 6 Material of construction: X concrete _metal _fiberglass _„_polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 6 ' X 10 5 " Sludge depth: -4 " Distance from top of sludge to bottom of outlet tee or baf 10 4 " Scum thickness2— r�; 3 ,�r ,. _a Distance from top of scum to top of outlet tee or bathe: 0 " Distance from bottom of scum to bottom of outlet tee or bathe: '0 _ How were dimensions determined: � p R S 7 „r7QA t cc, Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: N/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 (on pumping recommendations, inlet and outlet tee or bathe condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 97 Forest Street N.An over, 1845 OwnerGrant & Jane Pearson Date of Inspection;T 1 10 2 0 0 2 TIGHT or;HOLDING TANK�4 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of -construction: concrete metal fiberglass ___polyethylene other(explain): Dimensions: Capacity: allons Design Flow: gallonstday Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): mping: Date of last pu Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOA X ' (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: oil 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.) Flow checked, OK PUMP CHAMBER: N p' (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of PUMP chamber, condition of pumps and appurtenances, etc.): 8 " Page 9 of 11 . OFFICIAL INSPECTION, FORM — NOT, FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART .C= SYSTEM INFORMATION (continued) Property Address: 97 Forest Street 45 Owner: Grant & Jane earson Date of Inspection: Ju y , 2002 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number.: ° X leaching trenches, number, Iength:Aurox. , 30'X2'—.3'X (3) Trenches leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS; N / A (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 Gayer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): pRIVy:N/A (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART�C SYSTEM INFORMATION (continued) Property Address: 97 Forest Street N.Andover, MA 845 Owner.'Grant & Jane Pearson Date of Inspection:Ju l v 1-6,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within. 100 feet. Locate where public water supply enters the building. J .,[t i i i • I ` n iy[,• ` rlr titL07 jAj er t' F ,,M.,,.,,.,..,.....l \0n ,► 2.0- Lor Z f {, si .• ` vT �o � •.y � :i� a ,:?: �; N •+ 4,. � 010 40 Isp 00 rpr �t a j O'; � r• � Q 15P% , 'N { ( ;1\ f'':'2 •��•9 is • • •• t•. ., J' .41:i I I NO Oft 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (omonwd) P"P*m A"1 97 Forest Street _N�, Andgy r, _U 01845 Owren. (rant R Tan Pearson Drts st)w/eegwtt _T,,, ,4,.2�l12... . SM DXAU Surface wow . Chak sellw Shallow welts Eetimotsd depth to vwmw ww qmo"— test Plass indicots (o4ecic) W aitbads wed to dow:ww the hiSb glad wusr swatloa: � qmm de P Plw oa record • If olwsdw4 dots of dul p plop rwiswsd:.� -�► site (4Kftf propwTY1abW'*Qn Aolt waft In tot of SAS) ._. CDe" wa bat Dowd of d Clrclood with Ioatl txqvrqmon,„ly. (MtKh d�toa) Aeaeeod VSOS dwbtw "ORO You rule dw-ribs bow You a ftbUa W do bigb =rowad water sier•tiop: I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 I ARGEO PAUL CELLUCCI Governor BOB DURAND JANE SWIFT Secretary Lieutenant Governor LAUREN A. LISS Commissioner October 3, 2000 Local Boards of Health and DEP Approved Title 5 System Inspectors Re: Revised Title S System Inspection Form Dear Board of Health Members and Title 5 System Inspectors: The Department of Environmental Protection recently modified the Title 5 System Inspection Form. The date of this modification was July 15, 2000. This date is noted at the bottom of the revised form. Here is a brief overview of the changes made to the form: L �16' form is noted as an Official Inspection -Form. This form is not to be used for a voluntary ss essment of a Title 5. system. Completion of the form indicates that an official Title 5 system inspection was performed. 2. The. form now contains a disclaimer, at the bottom of the first page, which states that the inspection indicates the condition of the system at the time of inspection only. 3. The form reiterates the requirement to complete Section D of part A for all inspections. 4. The sform clarifies language regarding metal septic tanks (page 2), private well analysis (pages 3 and 4), and large systems (page 4). 5. The form provides more spacing for name and address information and has a cleaner presentation. Please discard all other versions of the inspection form and begin using the updated version that is enclosed with this letter. Should you have any questions or comments regarding the form, please contact the appropriate DEP Regional Title 5 contact. Sincerely, AWQ Lealdon Langley, Director enclosure Watershed Permitting Program cc: DEP Regional Offices Attn: Title 5 contact DEP Millbury Attn: John Higgins This information is available In alternate format by ealNoB our ADA Coordinator at (617) 574-6872. DEP on Me World Wide Web: htip://www.state.ma.us/dep Printed on Recycled Paper T zi L0 � � h _-------''"ter I5L N O O L CT" ZO (07- /9 I SLOPE /Z6:01111MAoo1ENT — ....... DESIGN 6-I-EV,47-ION 47 ......... (TOP OF STONE) EX/5T/NCS ELEI/,1T/ON 47 ......... 2EQ11/,eF0 F/LL = lFz&1.4T/ONS DE5/�N A.S 30/LT INV P/PE OUT OF /1OUSE / Sy, 7S INV P/PE /INTO TANK I Sy, f / INV PIPE OUT OF T4NK o6 INV PIPE INTO D. 230Y / S ?. -;� L( 6 7 INV P/PE OUT OF D. BOX /S 3 67 1.,5-_;S.55_ INV END OF PIPE 153 `-) 5-3 ti 6 GV.4TE2 EL E_114 TION 1 U U ,4 VE1eA6 E STONE DEPTH ,4T f0,eo5E A/OTE: 7-11/3 PL,4N /5 NOT .4 GV,4,e�E',41V7_Y OF 71.1E SYSTEM BUT 4 t1E1F/C,4T/ON OF T#E LOCATION OF 71.1E EY1STING STPUC7U2E,S. SUB-SU2FGCE D/S SYSTEM NORr� /,Yvw::R , r•,n F02 SCALE.' / rr= �/] D4TE•;�� C��%ST/,4N,SEN ENS//VE;7eIN6.0 INC. //4 ACENOZ,4 AVE., 11,,4VEelIlLL, A-14. z{ W a _ z Q C rt O C A v I. O n D I i ro o for o c c� 1 06 10 rtO pr 0 e S V C -t O H CD O I � v 0 c 3 c� rt a 0 r�. 0 flJ N W (D ii 0 V) (D fl.. M r+ (D 0 h E v CO to rn 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary DAVIDB. STRUHS Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 - n � CERTIFICATION Property Addras - 9 7 2 S�• ,1/r /�I, 19M14Nams of Owner e,n Address of Owner: Data of Inspadion: / Nameof.inspector:l Print) aV► am a DEP ved s ins • pectorp to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: ciAA Meft Address: ,Telsp)tow fitly": +-I '70 14 0O s'. CERTIFICATION STATEMENT certify that I havd 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: ZFa$ses Conditionally Passes. ss ' R_ Needs rthar Evaluation By the Local Approving Authority —.Fails Inspector's Signature: Date: R ' The System Inspectors 1 ubmit a c py of th' inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection If the syst m 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 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. .5 NOTES AND COMMENTS. A. iJ,ei S r i { } kl t 9 y L 1 i z ( r 1 14 = of j ,i revised 9-/2'/98 5 Page 1 of 11 0 Printed on Rerycled Paner ? r^ r t�^ J �1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ;•• CERTIFICATION (continued) r nn --froperty Address: C1 7 Ore -5 YIG� 0 U L I"YYl f} D 12, '45 Owner: `TFiadd eiis�i Ck.IClS I � Wrar of Inapecdon: ., y � 13 j o0 • INSPECTWN SUMMARY: : Check B, C, o/ D:' t A. SY PASSES; 1 have not found any information which indicates that an of the failure conditions described in 31 Y 0 CMR 15.303 exist. t. An failure Any ue criteria not evaluated are indicated below. ;.a COMMENTS; k:. 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. ;. 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 r P e ther o not metal, is cracked, structurally unsound shows substantial infiltration or exfiltra ' Uon, or tank i 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). r' R broken pipe(s) are replaced obstruction is removed distribution box is levelled 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): brokoni e() are a refaced obstruction is removed k k i.•i. I � I j ,1 r *Note, TITLE 5 INSPECTION S ON IS N7P A GUARANTEE/WARRANTY OF THE F[Tr[JRE FUNCTION OF THE SEPTIC SYSTEM. 'rev].13Ed 19/2/98 Page 2of11 i r Gk SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I. Propels Addraas: A1 TO rest . �-t fi N, } nd 0 Ver, VYl A 4 l is y s -�:`' owner:: � � :'TFC-dd21:iS�Z►cka�:t-ds .. Date of I<IipaC[y0n. N ► 3 D 0 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. , f s ¢ 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W 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: t +, 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) • ` SYSTEMA 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 1 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). , r, 3) w ; OTHER. 11 t 1 k M e r 3 ( r - 7 j 11 a.. 1 III r ! 1 'xEV1Sed' 9/2/98 Page 3of11 s f } , 1 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 2'e } l +� d Property Address:', q Drest 34 N: AY\Ao pd. rj YY1 A D t 8y5 Owni' hspectionP �1G�idt:u..S�:r ckcuolS . . n 04teof H113100 SYSTEM FAILS. You must indicate either *".Yes'". or "No" to each of the following: 1 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 j a' .•..Any portion of the Soil Absorption System, cosapoOl 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 60 feat of a private water supply well. sm 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: Ye 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 i. 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 focal regional office of the Department for further information. p. ?' revised ;9/2';/98 Page dofll J. e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B .. CHECKLIST Y Property Address; q?0a^GS� S �'.' ll� �, ► o e r, yYl R o l sit 5 Owner:. F ' �1Fiu.dd u is�{Zi cka:rds Pau of Irrspection; � H (13� d 0 . Check If the following have been done: You must indicate either "Yes" or "No" as to each of the following: Pumping information was provided by the owner, occupant, or Board of Health. •• None of he's stem components have been pum ed 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 asart of this p Inspection. a� As built plans have been obtained and examined. Note if they are not available with N/A. '`'`' •y.. ;^'+ ..''''The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. ' •�! ' xIsite was inspected for signs of breakout. •The Alt system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on: d► Existing information. For example, Plan at B.O.H. Determined in the field (if any of he failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)l °The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. t t . E t ++j i . ij:revised. 9/2/98 Page sotZi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION o re -nit S -k. K 4 vtA o der, M A 0 1 g 4 S Owner: Date of 4,11310 0 FLOW CONDITIONS RESIDENTIAL: Design. flow.—I&O-9-p.d./bodropm. Number of bedrooms (do 19n):ctual): Number of bedrooms ia .:Total DESIGN i Number of current residents: a V -b .-D Garbage grinder (yes or no): jPtcowdyne Laundry (separate system) (yea or no)w, If, yes, separate Inspectio required Laundry system inspected (yes or no) ;0080n at use (yes or no)..JZ Water motor readings, If available past two year's usage (gpd): Sump Pump (yes or no): -&O Lost date. of occupancy:Ei�" COMMERCIALANDUSTRIAL& 'Type of establishment: AIM Design flow: and Based an 15.203) Basis of design flow Grease trap present: lyes or no) Industrial Waste Holding Tank present: (yes or fic Non -sanitary waste discharged to the Title 6 system: (yes or no) Water motor, readings, if available. Last dots of occupancy: OTHER: (Describe) 'ast date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumpedlas part of 1A.Da', or no) If yes, volume pumped:gains 41, Reason for pumping: TYPE AF 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) 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: Saw ad when arriving at the site: (yes ,* "P odor*, detect r no) .,3!revis6d �9.�2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address. R;` orest St, Ill.flncfo0er� MA MTgG- ."i�10.dGC�us� i Ckdi,rds { ;r 4Data of kispecOgn -i l 13 t a o ' BUILDING SEWER :(Locate on site plan) Depth below grade:,, Material of construction: cast iron _ 40 PVC , other (explain) s Distance frAPtivate water supply well or suction line .,Diameter Comments: condition of joints, venting, evidence of leakage, etc.) ' 7 SEPTIC TANK:(�v (locate.on site plan): . Depth below grader Material of construction:concrete „metal _Fiberglass ,_Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) :. Dimensions: Sludge depth; Y Distance from top of aludg� to bottom of outlet tae or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: �/ Distance'from bottom of scum to bottom 'of1outlet tee or baffle: t3t♦ How dimensions were determined:1==�L Comments . (recommendation for pumping, condition of inlet and outlet toes or baffles, dept of li�luid bI�evel in relation to outle i vert��sstryyctura eXidence of leakag etc.) rno Z�.a�6 _ b/�j{[p � !/e]sfirr, n ✓� �. f GREASE TRAP: (locate on site plappn) " F Depth below grade• Material of construction: _concrete _metal FiberglassPolyethylene _other(explain) Dimensions: !'; Scum thickness: ;Z:r ~' 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: S 1iCommsn";W1 (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, etc.) 4 i � revised,l9/2/98 Page 7or1t '4 f' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property AddressN.4ftAtutr rn-A ot%L-is "Daft of,kopw6im: .411-3100 TIGHT'OR HOLDING TANK (Tank must be pumpedrior to, or at time of, inspection) P (locate on site plan). "Depth below grade, Material of construction: _.•concreto metal Fiberglass Polyethylene other(explain) Dimensions: Capacity:_—,�� gallons Design flow: _.;��, gallons/day J., p Alarm present Alarm level Alarm in working order: Yes No D f Date o previous pumping: (condition of Inlet too, condition of alarm and flout switches, etc.) . DISTRIBUTION SOX (locate on site plan) j� "i"4pth of liquid level above outlet invert: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc. "VAAW n 01 Pumps In .working' order: (Yes, or No) Alarms in working order (Yes or No 41 Comments: Jnote. condition of pump chamber, condition of pumps and appurtenances, etc.) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' 'Property Address: qri:Torest Si. N. •AmAo ue r, MA D 1, g4S Owner: T add e u s`R ex�aCs Daw of d: y1r!,1o0 v SOIL ABSQRPTIOIM SYSTEM (SAS): (locate on sits pian, if possible; excavation not required, location may be approximated by non -intrusive methods) not locatod, .*xplain; �.S 6. Type } leaching piU, number:_ . leaching chambers, number. _ " e leaching"galleries, number: ' leaching trenches, number, length: _ J leaching fields, number, dimensions: overflow cesspool, number: iV., Alternative system: Name of Technology Comments :.(note condition.of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: A AV s (locate an site pi Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: c TM. Depth of scum layer- `" r Dimensions of cesspool: Materials of construction: Indication of groundwater: :,ic• :. ` i. ... inflow (cesspool must be pumped as part of inspection) ir S .Comments f = ;(notecondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) I ,. po�ats on is an x Materials'of construction: � Dimensions: Depth of solids- - -Commenw, _. + (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i. i i •' f � C, I 'j evi.sed''9/2/-98 Page 9of11 •rl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) q. -7 rye�s� t -ti'. . N' fl/y■rtdo u e r . ►'n o i �.u5` P —w1T t, I (M `' (�� VK-S�� `•�{..{/rNS .. 4 ' .. ' Dow of M tweon• a. �++�31ao { 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) L07 fr I 1514.00 +II 1 T ZO T..f. ,t i4 • Y 1. H a ;+ �tl rlyan • �� /04. �y t { 1, 1.i i.• 21 t I .�• j. oi l!I r I 1 rp f • .- 1 } J 9 j 1 I LQ�CJr. 8'' page 10ofit �"E x 15r. HOu�[ sel�n�.. rr.Nc V -WA R 0 A .'= A." 57 y a . i aij t � t j. oi l!I r I 1 rp f • .- 1 } J 9 j 1 I LQ�CJr. 8'' page 10ofit �"E x 15r. HOu�[ sel�n�.. rr.Nc V -WA R 0 A .'= i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prgperly Address ,; q7 DrZ A rlt_0 J 2t , 1' Ownar:. "f�a�ic� eus-R ckiu`ds Dow of Inspecpon •..;Mkt.. ''�'. • .. , ; , •. i.. MRCS ii Report name . Soil Type_ Typical depth to groundwater USGS Data website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water s Check Cellar Shallow wells fEstimated Depth to Groundwater _ Feet t' Y Please indicate all lthe methods used to determine High Groundwater Elevation; ,� i k, Oput,ed from Design Plans on record { Observed Site (Abutting property, observation hole, basement sump etc.) ! Determined from local conditions k Checked with local Board of health Checkedt FEMA Maps .1 . Cho9ked. pumping records Checked local excavators, installers +` Used OGS Data = Describe howl you established the High Groundwater Elevation. (Must be completed) 4A r ' 7i+i 1 .A I ij. �, k ) i 1 {1 F 5 1. •, t I � .I i. � .Irk' .. revised 9/2/98 Page II of 11 a4veh .c w Iwo a ©eo N aBeh � 1 I S'r1o0Zs��1SbS e+,4 C* —Iy fA I t T U2o \\',A�� l 1% 0 Z m �I O e1, =A 9 5 Pt t7 rn m '0 n V .+ �a .► ..► ..� 1'I I rt a ..fo 'rt .p aG q •O IO b ' t as as an Ft 3 w•�owlolololow 1I a e,� al «•© aOe 1a ao ao 0o m �o .o I so a ■ v �► 1 ®w ©Be ra rt i aN 11 1 \ •+for I a © or 0 m J i a■ \ 1 1.n \ C in"!' iSo a ww cawN114 m m ©, X. 16 Ii1 . VI cc I CS bwQulow C m p II JT1mmmmaD —1m IC 1 N o c � BA a -A 1 so I z"a=a IT 'J' i 1.0. g aaoNiie�rtrtlU2r.�o A b ao �o q •c+ Io rr t © �a1O%cgIotov 1 4r a o f h i m ® 11 a ICLoI a •,I .I .� .i to \ m e o x oa n N '� w'O 1 \{? m y©� !� c e a a y" Iia• Oa u© Q 2In CI) 0 17i vm V m tan tit N N v CA3 b a s a� a x Naw�wa 3 led aaaaam nye aolam"0---�� m a �W rt My 11 as I'? 0 I o w, 1 o Owr� o wS.r ma o r. 1 .. n Div IC Ink c 14mEdi Z r -► a .► ..► .� ..► 1 u . 15 "'a v W d b ID la •O ►D a0 t . QI 1Za LO boo*0aoIQ m we . rt> .. ©HM to. �1not r?u7V1V1ViQlafee O We Iw OwDBed In qN Wa2 0 0 to�o 3W1 rt rt \1I Ti.�• V 1M I N Z o+ m 1>9ma o ©m ~NNIVING7coOwa+ 1 ro•ea v p0 V7 W a aC w" w 1 as fMu 7JOWWMamw. t O N u ti"r C ct�wa�oro� Ind'■' i 9© \\\\\%% aQ �O b 0 ■O 'T 1 &" Mal all -i O In I .Ja al In old 3 � t w w PIS v� `a II II i i �+•� � 1 I �mo©m O aOo4r t 1 l cpm II\ I 1"iall ytii WNWNN1� j ^ ra II 1-A a •6-4 i to kn CAD a ",ea M 9 9 m 1 u 1w u u u 6—a 6.d NA O 11 1R \f 1 nRt -• .. . n n n n - n . .- — - - - TOWN OF NORTH ANDOVER.' MASSACHUSETTS ` OFFICE OF CONSERVATION COMMISSION AO f NOGTH 3?�•`��i0 '•.'e °oma TELEPHONE 683-7105 Pursuant to the authority;of .the 14etlan& Protection Act, Massachusetts General Laws Chapter 131,.Sebticz 40, as amended, and the Town of North ---Andover's Wetland Pro ec :ion By Law, the. continuation of the North Andover Conservation•Commission will hold.a'Public Hearing on December 199 1984 at 8:00 P.M. at the Town Building - ---- Meeting Room, 120 Main --Street, North Andover, MA on.the Notice of Intent of Lawrence Airport Commission'' to alter land at. Lots l & 2 Osgood Street for purposes of alterning and relocating an existing brook and general rerzrading and replanting. Plans are available at the Conservation Commission Office, Town Building, 120 MainStreet North Andover, KA, on Tuesday . f from 12:00 noon to 2:00 p.m. and by appointment.. By : A. C Ilva na Chai :mang . run once in the N.A. Citizen December 6. 1984 . Copies sent to: Planning Board / Board of Health / Public Works Highway Dept. Applicant Engineer DEQE 4 BOARD OF HEALTH No.Andover, Mass. APPROVED - Provideds DATE__4Z:: 719 SUBSURFACE DISPOSAL DESIGN CHECK LIST �'�FILJU�V I LOT #_20 R&� ST DISAPPROVED DATE Reasons: Title V Reg 2.5 _ _._... ._ Reg 6 Reg 10.2 Reg 10.4 FAIL CK The submitted plan must show as a min mw,: a) the lot to be served-area,dimensioas 1. t #,abutters blocation and log deep observation hoes-'istance to ties c location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area f) existing and proposed contours (g) location any wet areas Athin 1001 of sewage disposal system or . disclaimer -check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Hoard files (j) known sources of water mipply within 2001 of sewage disposal o . system or disclaimer (k) location of any. proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -IC' from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of baserw t, plumb, pipe, septic tank, distribution box inlets and outlets, d stribution field piping and Other elevations (r) maximum ground water elevation in P 'es sewage disposal system (s) plan must be prepared by a Professi.onaL, Engineer or other professional authorized by law to preparr such plans Septic Tanks (a) capacities -150$ of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Distribution Boxes (a) slope greater th 0.08 b) sunp Lot 13 Forest St. 1/ E.4atthier A. i APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. , I hereby make application for a permit for a sewage disposal install Lot 1 Forest St. . I will install this system cordance with all the laws of the Commonwealth of Massachusetts and regula the Board of Health of the Town of North Andover. tion at Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 1000 in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and lalf in a series of trenches, the bottom of which will pro- vide a minimum of lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.)-and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further arree not to cover anv portion of thin installation iintil annrnvAd by tho e any additional requirements submitted with application. DATE 5/22/72 \ t ignature of Appl'iter I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE 5/22/72 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE % 11 Percolation Test 9 Minutes Soil: ag Garbage Grinder OF FRANK C. c3 GELINAS o .No-. 22738 I Sr ONAI_ to Ore. L_ PCCJ Q_r V; Fr_ Vni I t Y7 ee I- ve 6.:s ,S/ t I -71. k^� c c. � � a M i M il -4 n` Q m � cc, � Q � ct col Q J Loam Loam 03 -1•4S V UZO- G 1--V. -!4AS v� V s \Sv t 10 1. a rev. = ,2 L oam Loa ALO U V - u-20 E `34.(7 -rsST 4 �0 ti op 6 9r� II 4VlyGt1= Ct— ct d 0- _ lZr . i �0 e ti op 6 9r� II 4VlyGt1= lZr p 4 e V ' s 3 t?' .,y S NI j. t BOARD OF HEALTH :,F NORTH ANDOVER, MASS. 2 kz 1 0Y ol 1. NAME CL « 7 Gj t'r DATE L '- Z 7 2. ADDRESS 1'r�' f' � � S ��'�' � � t I, \ LOT NO . E' T— � >? � � � v �= . 3. NO. OF BED'�[;OMS 3 DEN nS NO �- L4. GARBAGE GRLI IER YES NO 5. SHOW DIMEN 3.C:; CF HO'1 E b. SHOW DISTANCES OE H0113E TO ALL PROPERTY LINES 7. SNOW DIMENSIONS OF LOT �. 5HC.ld LOCA -'ION AN ' SIZE; OF SEPTIC TANK OR CESSPOOL �. NC"-- 'C',,' -ION AND CIS TANCE OF WELL FROM SEWERAGE ��. It ION OE' BROOKS, STREAMS, DiICHES, I,E:,GE 0UICn"cl , E':C. 1 _. -,TAN,--E OF :SEPTIC TANK OR CE=.'r�:C: F'RO t HOUSE t-- 110:'F:: IUCAl :;H AUL: BE READ CAFLEK' LY. °�-iY < d kjl c.1N U) N G\ "Zj-. 11 a� 12-.m OF 7(j lob 1 f'