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Miscellaneous - 98 FULLER ROAD 4/30/2018
N 1� 1 SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW CONDITIONS OF APPROVAL (FROM FORM U) YES NO NEW REPAIR YES YES NO ISSUANCE OF DWC PERMITES NO DWC PERMIT PAID? ��`�___/ NO DWC PERMIT NO. S/ % INSTALLER : -Fnp p B -r�56 k) BEGIN INSPECTION YES NO: EXCAVATION INSPECTION: NEEDED: PASSEDy`/ /96 BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: BY FINAL GRADING APPROVAL: DATE BY o FINAL CONSTRUCTION APPROVAL: DATE: BY Commonwealth of Massachusetts City/Town of 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•Pag,Lefft/ lg front of hous , Left / Right rear of house, Left/ right side of house, Left / Right side of buil Rlg o building, Left/ Right rear of building, Under deck Address myrrown State Zip Code 2. System Owner. Name Address (if different from location) Cityfrown U State �ede 1CV\� Telephone Number a B. Pumping Record �— 1. Date of Pumping p�2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Ic Tank ❑ Tight Tank 4. ❑ Other (describe): Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition 6) of s em:��� _ 1 v, 6. System Pumped By: 7. t5form4.doc- 06/03 Neil. Bateson Name Bateson Enterprises Inc' Company contents were disposed: F5821 Vehicle License Number System Pumping Record • Page 1 of 1 F t «��,.4;� : � � # % \fes � �� �°� `\ v � ��� � .\ � � v .' � � �� � � . . ��� � � \ \ . _� .� � :� _ °� z� 9� > , .§��/ . �. " \� / � »�, »��\^� o 1, _W r 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. ISI ILEI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover MA 01845 8/12/2013 City/rown 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 Cityfrown 978-475-4786 Telephone Number B. Certification MA State S115 License Number 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 ❑ee Further Evaluation by the Local Approving Authority 8/12/2013 In pector s Signat 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 • 3/13 Title 5 Official Inspection Form: 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 98 Fuller Road Property Address Maura Flaherty Owner Owners Name information is required for North Andover MA 01845 8/12/2013 every page. Citylrown 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 outlet tee in septic tank, new d -box with riser, inspection from B.O.H., septic system now passes Title 5 Inspection. 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 • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Of NOR7 .,M O O ❑ Animal $ Town of North Andover ��'•�;, o �:,' ,sS�CNU`+tt HEALTH DEPARTMENT CHECK #:DATE: Body Art Practitioner I LOCATION: if Ro, H/ O NAME: V41A 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ )� Title 5 Report $� ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer I 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. Ibl ILEI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover Cityrrown MA n1RdF RECEIVED a jU 2013 an TOWN OF NORTH A EH HEALTH DEPAR T It% 7/3/2013 t v [ 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 /I A. General Information 1 Inspector: Neil J. Bateson Name of Inspector Bateson EnterDri Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Inc. fit% Z MA State S115 License Number 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 ❑ Needs urther valuation by the Local Approving Authority 7/3/2013 Inspector's Signature V 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 n Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road Property Address Maura Flaherty Owners Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 7/3/2013 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ 1 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. I . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover MA 01845 7/3/2013 Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 t5ins • 3113 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 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover MA 01845 7/3/2013 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Outlet tee in septic tank & d -box needs to be replaced. D -box needs riser 3' deep 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 '/z day flow t5ins • 3/13 Title 5 Official Ins pedion Form: Subsurface Sewage Disposal System •Page 4 of 17 1 -t\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road Property Address Maura Flaherty Owner Owner's Name information is required for North Andover MA 01845 7/3/2013 every page. Cityrrown 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road Property Address Maura Flaherty Owner Owner's Name information is required North Andover MA 01845 every page. Cityrrown State Zip Code C. Checklist 7/3/2013 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): -J!4- DESIGN DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3/13 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 98 Fuller Road Property Address Maura Flaherty Owner Owner's Name information is required for North Andover MA 01845 7/3/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information Yes ❑ No ❑ Description: ❑ No ❑ Yes ❑ No Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System •Page 7 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 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 7/3/2013 State I Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped Dec. 2012, owner gallons ❑ Yes ❑ No ® 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''r 98 Fuller Road Property Address Maura Flaherty Owner Owner's Name information is required for North Andover MA 01845 7/3/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 17 years old, 5/2/1996, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No 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" Cast iron through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 1" ❑ Yes ❑ No t5ins • 3/13 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 M 98 Fuller Road Property Address Maura Flaherty Owner Owner's Name information is required for North Andover MA 01845 7/3/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Inlet baffle ok. Inlet cover in walkway. outlet tee corroded on top, needs to be replaced. Depth of liquid at outlet invert, no evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 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 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover MA 01845 7/3/2013 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover MA 01845 7/3/2013 City/Town State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal, has flow levelers. no evidence of leakage. Evidence of carryover. D -box has bad corrosion, needs to be replaced. A riser on d -box also needs to be installed. d -box 3' dee[). 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts PJ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road Property Address Maura Flaherty Owner Owner's Name information is required for North Andover MA 01845 7/3/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 50' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 13 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road 7/3/2013 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Property Address Maura Flaherty Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code 7/3/2013 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 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 98 Fuller Road Property Address Maura Flaherty Owner's Name North Andover MA 01845 7/3/2013 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately all t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road D. System Information (cont.) Site Exam: ® Property Address ® Maura Flaherty Owner Owner's Name information is required for North Andover MA 0.1845 every page. Cityrrown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 7/3/2013 Date of Inspection 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: 11/20/1995 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Desian Dlan ❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Fuller Road Property Address Maura Flaherty Owner Owner's Name information is required for North Andover MA 01845 7/3/2013 every page. CityrFown 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 • Summary Record Card generated on 6/20/2013 2:53:34 PM by Karen Hanlon Town of North Andover Tax Map # 210-065.0-0083-0000.0 Parcel Id 15308 98 FULLER ROAD FLAHERTY, MAURA 98 FULLER ROAD N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2013 UB Mailina Index Name/Address FLAHERTY, MAURA 98. FULLER ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17210.0 - 98 FULLER ROAD 3160288 03 Cycle 03 UB Services Maint. Account No. 3160288 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3160288 Serial No Status 32772962 a Active Date 3/6/2013 12/7/2012 9/5/2012 6/6/2012 3/8/2012 12/5/2011 9/7/2011 6/6/2011 3/3/2011 12/6/2010 9/7/2010 6/3/2010 3/5/2010 12/7/2009 9/3/2009 6/3/2009 3/10/2009 12/4/2008 9/4/2008 6/4/2008 Trouble Code:03 3/6/2008 12/6/2007 9/13/2007 6/12/2007 3/9/2007 12/5/2006 9/6/2006 6/12/2006 Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 4/10/2013 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 38.00 /1 Until Location Brand Type Size YTD Cons 00 b Badger w Water 0.63 0.63 -- 590 Reading Code Consumption Posted Date Variance 732 a Actual 10 4/22/2013 4% 722 a Actual 10 1/9/2013 -88% 712 a Actual 85 10/15/2012 664% 627 a Actual 11 7/16/2012 4% 616 a Actual 11 4/14/2012 -5% 605 a Actual 11 1/17/2012 -77% 594 a Actual 51 10/13/2011 301% 543 a Actual 13 7/20/2011 19% 530 a Actual 10 4/13/2011 -26% 520 aActual 14 1/12/2011 -91% 506 a Actual 165 10/15/2010 1090% 341 a Actual 13 7/15/2010 -9% 328 a Actual 14 4/14/2010 -31% 314 a Actual 22 1/12/2010 -3% 292 a Actual 22 10/15/2009 56% 270 a Actual 13 7/20/2009 -8% 257 a Actual 16 4/29/2009 -76% 241 a Actual 62 1/20/2009 198% 179 a Actual 21 10/10/2008 28% 158 a Actual 16 7/16/2008 8% 142 a Actual 15 4/11/2008 -13% 127 a Actual 16 1/22/2008 -19% 111 a Actual 22 10/12/2007 32% 89 a Actual 17 7/20/2007 -1% 72 a Actual 17 4/16/2007 -4% 55 a Actual 17 1/19/2007 -40% 38 a Actual 27 10/20/2006 86% 11 a Actual 11 7/10/2006 0% n Commonwealth of Massachusetts Map -Block -Lot 065.00083 BOARD OF HEALTH Permit No North Andover BHP -2013-0815 P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson to (Repair) an Individual Sewage Disposal System. 'bl at No 98 FULLER ROAD ------------------------------------------------------------------------------------------------------------------ - -qq- --------------- as shown on the application for Disposal Works Construction Permit No. Bated �_I- HP-2013-081 DI.O/_� ---------.•- ----- ------ - ' 7? Issued On: Jul -18-2013 `� "� .ARD OF T � //� - -- - ---------------------------------------------------------- 00 Commonwealth of Massachusetts Map -Block -Lot ----------------------- 065.00083 AC BOARD OF HEALTH North Andover C TIFI ATE OF COM IANC �NW 4 COMP I , 'ERT That so I S "ste THIS CERTIFY That he Individual Sewage sposal System (Rep by 'I'Odd Bateson/ ------------- ----- - -- ------------------ alter----- ------------------------------------- - ---------- atNo--9-8- FULLER ROAD ------------------------------------------------------------------------------------------------------------------------- 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-2013-08 Dated ------------------------------ ---------------------- -------------------- Printed On: -- Jul - -18-2013 -------------------------------------------------- BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 065.00083 BOARD OF HEALTH ----------------------- Permit No North Andover ----------------------- BHP -2013-08 15 FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted ToddBateson----------------------------------------------------------------------------------------- bto (Repair) an Individual Sewage Disposal System. at No --9-8- FULLER- ROAD ----------------------------------------------- ------- ---------------------------- �611't 777- r n Ply as shown on the application for Disposal Works Construction Permit No. BHP -2013-081 t�m,,,76X Issued On: Jul -18-2013 . . ................................................ ------------------ - ------ ------ ---- ---- -- - -------- BOARD OF HEALTH ' "°'.`'' . Application for Septic Disposal System 17— / 7 I—) Construction Permit - TOWN OF TODAY'S DATE Full Repair NORTH ANDOVER, MA. 01845 $,2s.0o-Component Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Construct a new on-site sewage disposal system* ❑ replace an existing on-site sewage disposal system* ZZror replace an existing system component –What? t) A. Facility Information Address or Lot # Ciryrrown JUL -18 1013 2.- *TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER ➢ ❑ Pump ravity (choose one) HEALTH DEPARTMENT ***If pump system, attach copy of electrical permit to application— ➢ B;Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install_ this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? 2. Owner Information What is the Model. Name Address (if different from above) a // ld /�p City/Town State Zip Code Telephone Number 3. Installer Information Name Address I ,4-� IAI, - a av C) Cityrrown 4. Designer Information Name Address Cityfrown Name 6XIMM ENTERPRISES, INC. 111 ARGILLA ROAD State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System 117- /3 Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $ 250.00 - Full Repair $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 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. l understand that until a final Certificate of Compliance has been issued by this Board ofealth, the installed system is not approved. 4�_ �--- / -7-�� Name Date Application Ap 6oved By: Pbard of Health Representative) Name Date Appli tion Disapproved f r the following reasons: ForOffice Use Only.,___.__.__�m.a-.........,.�.._...�...�._-...�....,__._�...�..-�.�,.. _.._m �...... Z Fee Attached? Yes No 2. Project Manager Obligation Form AttachedP Yes No I Pump System? Ifso, Attach copy ofElectrical Permit Yes No 4. Reviewed approvalletter, all paperwork received. -P Yes No Missing.. 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 I M J SEP'Z'IC'SYSTEM.INS�ALL ERTRGJECT MWAGEMEN' OBLIGATIONS As the -North Andover licensed installer for the construction fOs:the septic systern'for.the•property at For plans by (Address of septic system) (Engineer) Relative to the.application of ���✓� And dated staller's name) r�gina a. e . Dated r] — ` 3 With revisions dated -k1 oda s a e (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, p)riOT to performutig any:work on a site: I mut have the approved plans and the ,permit: on site when any work is call for any and altinsptctions: If homeowner, contractor,.project manager, or any 2. As fhe installer;.I must other person notassociated with my company schedules aan inspection and the system is not ready, then item three sh4 be: applicable. .` As •thy astafler, I atm••requi .red to. have .the aecessAty work'com01eted Vior to the .applicable inspections as indicated belo m, T.. defl:tand that rea tt's : n iii. p� 4.lI,: , �f• �' pletion: of the items in accordanc a, .. BottoYri ttf.ed Generally, this. is the fizsk (1"j in'specttom unless: there is a "retaining wall,Which. shotdi •be dnae<iYrst: Thcjnstallrx,r Mu. -quest theiiispectidn but cloesnot have to be pttsent . b. Fina..�onns} tjori. tt peetidti — Engaeer mus't'fixst da rheic inspection for elevations, ties, etc. As-bi3ilti of verbal OK dor a -mail •to: healtlid;n�to 0 olthaindover.��, from the engineer must •be stibniitfed.to :the.Board'.ofHealth, after'.aaliietiinstaller.calls for -an ins pectipn time. 'Installer must be present for this.inspection, With •a pump system, all• clectrical *, ori :' f be ready and able to cause piinv t6 vt &k gAd. alaun'.to fbt otion. . C. Fin ; �Gtado installer must request inspection vwheii'O •grading'is compltte..Installer *does' not have to be •on4ite. ; 4. As -the installer,' I mntieistand that only I•nay perform the wofk(other than ihVe excavation) and 'I ani required to complete the installatian of the system identified in the athched application for installation: J flirthe.. .understand•that work •done by others uiili'cense s c' stems •in North And can Eon'stttute reasons for denial•df tltLWtem and/or gvocation or siist5erisiori Qf.my license•to operate in. the Td, vn of oA An over. s ficant fines to all parsons.ui'vQLvedire also possible. 5.. As the.instiller, I understand that.I;nu§tbe orl-.site during th .Perfcirniance .of tTie following construction. steps:.. a: Detenuinatiod that.the privper elevation ofthe'eream. on has been reached b. Inspection ofthe'sand aad storie'to be used. c. Final inspection by Boa& of.Flea kh staff or consultant. d. Installation,oftank, D -Box pipes, stone, vent, primp chamber, mtaraLV walfand other . components. , G. Undersigned:icensed eptic.Iastallex: (Z'Qdag Date) C LLJ -j�� Q W u... Z:) Q �QJ>- q `LW Zw V ,.Lij Llcn dW Q LL 1 ul o o Xs ¢W a LU Q 0 o LL ° W 0 L 0 a 2 cn -/ F ����� J j\ �1 QwQ Z d J ¢ L) 2 } J , < w Q a :1 C] g .71 O� u3 >- C3 ilI d� p fcn -- Q V to IT O CWC G m O �0 Z . Z X w H Q � 2 LU � n O\ � 7 Q ^ O O W UJ � FI � J) a: W Q O � LL Cl I n W 5 " rn Commonwealth of Massachusetts City/Town of S stem Pum in Record Form 4 2013 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: eft Rig runt of house eft / Right rear of house, Left / right side of house, Left / Right side of buil g, Left / Right front of building, Left / Right rear of building, Under deck Address 6 25 TRA" City/Town 2. System Owner. Name Address (if different from location) Cityrrown State Zip Code State 7 Zip Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quan " -Pumped 3. Type of system: ❑ Cesspooi(s) eptic Tank ❑ Other (describe): Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ErNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condit ign C)f' ` "�`-'.i� Q V\- Vi� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: ISIgnt AHaule Lowell Waste Water Dat t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _I�= Commonwealth of Massachusetts City/Town of System Pumping Record OCT 15 2007 - Form 4 DEP has provided this form for use by local Boa rds.of. Health. Other foam may be used, but the inforrnation 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 Address C*r-rown State 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping �0 Date Zip Code State &— —1?9ZP, /e Telephone Number y 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): �, 4. Effluent Tee Filter present? ❑ Yes L�'No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio System: l � 6. System WMpe2dEjy,,,, _ V'\ � Name Vehicle License Number Company 7. Location is wire used: ) CD Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Date ... yx/.!� .-? ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . � �� 4 f-?,. . ., 7 f has permission for ps installation in the buildings of fY, s14. .at .... North Andover, Mass. Fee. Lic. No.. .. .... ...... v-7%, ..... G'AS INSPECTOR Check 6053 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. DateX Q Permit # CO� Building Location Owner's Name P1,4 dvL/ Type of Occupancy G New ®/ Renovation ❑ Replacement E] Plans Submitted: Yes[] No ❑ Installing Company Name, G/ LL 4&42i As�t � Check one: Address j / �li� `S' D—Corporation --��-- z�fr�� SS ❑ Partnership Business Telephone �J f� ���'�� �3 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Cjf-L/ Certificate / 6 /I C L INSURANCE COVERAGE: I have a current abllfty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes LIZ No ❑ If you have checked Yes, pleas Indicate the type coverage by checking the appropriate box. A liability Insurance policy - Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under thepermlt Issued for this application will be In compliance with ali pertinent provisions of the Massachusetts State Gas Code and Chapter 142 or the Gene al taws. T e of License: Title Plumber Sig Y lu e of Lic6nsedPlumber or Gas Fitter asfitlor City/Town aster License Number y7� IU f ix7VFn—�pfTTJourneyman - O �V=NMNEMNEEMMEJ MINE M 0 0 1 no MEN 0 ��MNNNEJNMENMJNE ONE MEN moomm ME MEN NEON soon NEEMMENEMMENMEM 1010no, Installing Company Name, G/ LL 4&42i As�t � Check one: Address j / �li� `S' D—Corporation --��-- z�fr�� SS ❑ Partnership Business Telephone �J f� ���'�� �3 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Cjf-L/ Certificate / 6 /I C L INSURANCE COVERAGE: I have a current abllfty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes LIZ No ❑ If you have checked Yes, pleas Indicate the type coverage by checking the appropriate box. A liability Insurance policy - Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under thepermlt Issued for this application will be In compliance with ali pertinent provisions of the Massachusetts State Gas Code and Chapter 142 or the Gene al taws. T e of License: Title Plumber Sig Y lu e of Lic6nsedPlumber or Gas Fitter asfitlor City/Town aster License Number y7� IU f ix7VFn—�pfTTJourneyman - O 9 rt� C a c rt a V) (D' cr) O (D k �LRI C rt (D O h zn v rt G n v o A D D o' 3 (D Dvv Arr O C (D D � O (D �" D rr 1 (p O (D iDiD D D f'h Z Z H m D n C fT nD A iy � CL {I I fD C a c rt a V) (D' cr) O (D k �LRI C rt (D O h Date...'2.7 .. ::.-...� ---.....7 ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... ......................... i�:-� . . . ................................ has permission to perform ............. . ........ ............ x., - X-1— .......... ......................... wiring in the building of...... �e ................................................. at ... ZZ ..... .. ........... 0 ............ . North Andover, Mass. Fee.!?. ...... ........ Lic.....(. .............................................. ELECTRICAL INSPECTOR Check # 470 V& C0910NWEAGW0T 9�",4CNVSE9TS Department of Tu6fic Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Official Use Only Permit No. g700 Occupancy & Fee Checked/��� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print In Ink or type all information) Town of The undersigned applies for a permit to perform the electrical work described below. 1 Location (Street & Number / y l ((?. f Date To the Inspector of Wires: Owner or Tenant E 1 Cl Owner's Address Is this permit in conjunction with a building permit Yes No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Vats Overhead 0 Undgmd 0 No. of Meters New Service Amps Vats Overhead 0 Undgmd 0 No. of Meters Number of Feeders and Ampacity c Location and Nature of Proposed Electrical Work I CC L/ c c, C, t/i !1 i C 's i C / OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Comp ed Operations Coverage or its substantial equivalent YES VINO,0 have submitted valid proof of same to the Office YES 4y NO 0 9 you haw" YES please indicate the type of ra a by checking the appropriate box INSURANCE n BOND 0 OTHER 0 (Please Specify) i� 66, /i%4 J/ l3�%e0 Estimated Value of Electrical Works / d 1::� (Exp ration Date) Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of FIRM NAME ____Le (�� (� _ LIC. NO._JJV 'rI-) �5h,, .Yvis Tel No. 510 I �3-0'-/ 2-i OWNER'S INSURANCE WAIVER: 1 am aware that the I*enses does not 'ha' General Laws. And that my signature on this permit application waives this NO. No. rance coverage or its substantial equivalent as required by Massachusetts it. Owner Agent (Please Check one) Telephone No. PERMIT FEE $_ (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 ,tlo. of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA No. of Emergency'Lighting 'No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No, of Di sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices 0 Municipal 0 Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Comp ed Operations Coverage or its substantial equivalent YES VINO,0 have submitted valid proof of same to the Office YES 4y NO 0 9 you haw" YES please indicate the type of ra a by checking the appropriate box INSURANCE n BOND 0 OTHER 0 (Please Specify) i� 66, /i%4 J/ l3�%e0 Estimated Value of Electrical Works / d 1::� (Exp ration Date) Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of FIRM NAME ____Le (�� (� _ LIC. NO._JJV 'rI-) �5h,, .Yvis Tel No. 510 I �3-0'-/ 2-i OWNER'S INSURANCE WAIVER: 1 am aware that the I*enses does not 'ha' General Laws. And that my signature on this permit application waives this NO. No. rance coverage or its substantial equivalent as required by Massachusetts it. Owner Agent (Please Check one) Telephone No. PERMIT FEE $_ (Signature of Owner or Agent) Conumonwe ith of Massachusetts N, ddvt`�. Massachusetts System Pumping Record System Owner &6 u s4e-t Date of Pumping: Cesspool: No Yes System Location q,P P -u 6(-ef Q. --A Quantity Pumped: /62t� gallons Septic Tank: No Yes «--' System Pumped by: Ncttedea Siffthi ded License # Contents transferrred to : Greater Lawrence Sanitary Dlstrict Date: Inspector- TCWN OF MORTH ANDOVER/ BCARD 0." HEALTH . _ x ,.7 JUL 1 2 lSS9 I TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: —19-01 STEM OWNER & ADDR] 1C�-kaI- SYSTEM LOCATION (example: left fronts of house) -F(-a&+ O -P }1p1,t5� DATE OF PUMPING: -Lq-a 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) J,.L-3 1 2001 CONTENTS TRANSFERRED TO: /�7 , Z—-- ----- —. 7- WN OF TORT+- .,. [MA1 ?J Or F'sf k1 r1 21996 r'Li Wr'( UHHAf-Y of _ 0V 612T�_6` �I'"GI,G ni'►�l �mm�- mnom Rte - E�iST, _.MEMO= 14 . `i aff r wow ®®�� lyi.03 Wi7 L6Ac4 Lws"I 14 a.l 1 ®mmm ,7Z ���mcmmm 3I Li 0.77- ----- —. 7- WN OF TORT+- .,. [MA1 ?J Or F'sf k1 r1 21996 r'Li Wr'( UHHAf-Y of _ 0V 612T�_6` �I'"GI,G ni'►�l Fits- �ti�t'. �jE�l�"rAtlK„t Rte - E�iST, E 14 . `i aff r P. lyi.03 Wi7 L6Ac4 Lws"I 14 a.l 1 42 ,7Z M 3I Li 0.77- q I, 537 f.. t Pte- %�peek 98 j a Pot -I& Kf. Q 15Qo � fiuiK � ut:W 20,E sv' LFbu l Ci t— AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN IJaeTi-I A"Dovev- AS PREPARED FOR .JOPc�.j AUGU`�TA / qb FuLI-EfL� 12D, DATE: MAY 2, 19cI(o SCALE: I' I. MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 or TEL (617) 473-3533, 373-3741 Cun1111uN0Afill il of AlaRfrsltl�us:ctlsa 1 NlossEtcltusetts sj�tsllmu�rno—5j�itet�i Lnciiion n LAA G rutiL hnie or NurrspinN 1.4' Ire! 0 lesss�suuis tris ��� 1'c! U . seJ b• ; b 64es n Llcet►se Ns Srsleoll I uss I Cunlenls IrnsisleirrJ Ir: + -" L)nle 1 lilsperlur r Conunonmeallb of Alassnchusetls� Massachusettsr36ARS) OF OF ysieiti I'umf��g recur ;�c. ��s cm oca ion Jv 1 ,i r Date oftu ing � ., .Putttied: t Cesspool: tics , yes tJ Sentir Tanl•, Nl- Yes Sstett � r Pumped by: ___I✓ oJes 0 ►� _ License !l: , Contents transferred to: Date Inspeclor COMMONWEALTH OF MASSACHUSETTS (^ _ - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION -= ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 7 CERTIFICATION Property Address: 1 1-\,) 0� V Nana of U s•° '` ll�. - ) �d S ( Address of owner Date of Inspection: f� - ,D?, Q_. ` t �, �P Narne of hu1mctor: (Please Print) �/ '_1t^ 1 am a D owed system ' pursuant to Section 15.340 of Tide 5 (31 O CMR 15.000) aompa av ddress. �' Telephone Number: t f CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage Nis osal systems. The system: C__ �P.sses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fa'I kispector's Signature: �' ' �-' �" ' Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 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 TCjNt OC t6'r,.-._ 1999 revised 9/2/98 Page Iof11 0 h Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIRC1ATION Icontinued) Property Address:f'Ie, 'itiell\". Owner: 1 r �j 1 Sri Date of Inspection: )-7 C�C� INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEMPASSES: L- 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 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 ND). 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 pipals) 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 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): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 151 Date of Inspection: 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 (10) 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 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERMRCA71ON (confirmed) Property Address: Owner: Date of Inspection: '� ? C -, __ U 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 110,000 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 inforjnation. revised 9,'2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No-- ( - -- _ Pumping information was provided by the owner, occupant, or Board of Health. L — None of the system components have been pumped for at least two weeks and the system has been•recelvingttotmall flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. ~' All -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: ' _ Existing information. For example, Plan at B.O.N. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)1 The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �( SYSTEM INFORMATION ,�L� Property Address: C��� Owner: Date of Inspection:��- r(_ FLOW CONDITIONS RESIDENTIAL: Design flow: 10 9-p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow q q 0 Number of current residents: i Garbage grinder (yes or no): -N�.J Laundry (separate system) (yes or no):WL� If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):NL? Water meter readings, if pv•ailable (last two year's usage (gpd): �� J PCr� Sump Pump (yes or no): W-1 _ Last date of occupancy: V 1V QI, t-7c�= COMMERCIAL/INDUSTRIAL: Type of establishment: Imo- ��� 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: System pumped as part of inspection: (yes or no) If yes, volume pumped: alloys ,( Reason for pumping: TYPE OF SYSTEM j �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) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other ,, () AP ope MA AGE of all components, dale installed (if known) and source of information: OC�1 1 �" 1c Sewage odors detected when arriving at the site: (yes or no) t - k) revised 9/2/98 P2ge6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (� SYSTEM INFORMATION (wed) NopertyAddress: Date of Inspection: BUILDING SEWERS , (Locate on site plan) u Depth below grade: Material of construction: ''c st iron ti'40 PVC other (exp n) h L f 0-9,1 3 �t��1r % V\ Distance from private water supply well or suction line Diameter (-j rl Comment (conditir of Jo'nts, venting, evidence of leakage, etc.) SEPTIC TANK: t---'" (locate on site plan) 1j Depth below grade: f 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: L lC ,-� �`` L� X-?, SaCc-'�i.Q Sludge depth: — ' Ll Distance from top of sludge to bottom of outlet tee or baffle: c Scum thickness: cv 1' c' 11 Distance from top of scum to top of outlet tee or baffle: U Distance from bottom of scum to bottom pf uC tCtee or baffle: How dimensions were determined: ,: J� t c''�" �-X.v�rv...,.b Comments: (recommendation for GREASE (locate on site plan) inlet Rand putlet teQs or baffles, deptq of liquid leivel irl relation to outlft invert, Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from tdp 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: (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.) revised 9/2/98 P2ge7of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j j r ` SYSTEM INFORMATION (conntin`ud) e Property AddresA: C_ 1 C' t J l l{� �. )C ` V �� ( v'A' '- Owner: C Date of Inspection: 1 ��'C TIGHT OR HOLDING TANK- ° '(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 _otherlexplain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.l DISTRIBUTION BOX.• (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if le�.I ancj flistri ution is equ I� evidence of solids ca ver, Lvidgn�e of I aka j►}fo or qut of box, etc.) lI ti-�C}� L` \�1`sv .��'i � L\ �\ iICQ_SL ��� i�`� CJ (iC_C�� V .1 JU VW4 4" PUMP CHAMBER: \N' WNC—., --c. (locate on site plan) J 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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORMA PART C SYSTEM INFORMATION lleontinuedl Property Address: V t I-zx- Wki� . 0C' V A- A "� . Owner: CUS-k- Date of inspection: SOIL ABSORPTION SYSTEM (SAS): (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:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length:-- �— -� , ` ( I leaching fields, number, dimensions: t - C N - �` — x Ea overflow cesspool, number: Alternative system: Name of Technology: Comments: CESSPOOLS: (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: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: ,DV\e— (locate on site plan) Materials of construction: Dintait3ionsi Depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of 'vegetation, etc.) revised 9/2/98 Page 4ofll t*1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR] C SYSTEM INFORMATION (continued) Property Address: Owner: j Date of Inspection: L��`(��`'� `tk,_ (' J � 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) revised 9/2/98 Page 10 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ( ( l 11 �SYSTEM INFORMATION (continued) Property Address: Owner: Date of spection:S. c _lC NRCS Report name 11 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 -�:t Feet Please indicate all the methods used to determine High Groundwater Elevation: L, -" Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) _ Determined from local conditions L- 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) 11 revised 9/2/98 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: C ��' G �p ,�-'�� ���c ,u L Owner: L�13 � Date of Inspection: 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. uI � QD Q 1p r4) z N W w v' o _0 1~' 0 �• Ld ~ o w Q W LD(� _ 4 NJ /I w o c W 09 C) LIO U') p O dN LLJ W CD c�1) W-- r� -i � 0� < W� O F-- N � W O V 1 —j CC ad Z 0w a- (�, � ``'� c!) (f) W W Q > O L,jry I) �!Lr) Z _j � .0 Z_ Z_ v CL }' I-= F- o a w ULo - OD a- u0OD WE)cn Zvi z 'zw oz JvFw oo O c o 'n _ -j W � W LL 0, r� O O W � Q o -I D ooa z CL ui o v x p wQ O—' XoQ w m m> LL- N Z uLa. . �W-- � _ CL )4Na1" Iv 0051 p � N J N F- tf t O N UJ M, N. N Z - O d ` W d' — Y U0 -- Y Z O ZQ ZQ 2 _ F- N Board' of Health North An ver Haas. X BEMC SISTEM INSTAI.LATICK CEMK LIST LOT J AVAnM OK FAIL 1. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3• No PPC Pipe 4. Septic Tank - a. _Tess -_Length & To Clea flat Covers. b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Fqual Amounts c. No Back Flow b. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone' 7. LeJ�hPi a.ons b.epth c.Pads d.e.Pipe to Pit - Both Sides. f.ouble Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Subn.tted. _ a. Lot Locations _ . - b.Dimensions of System c. Location with Regar&to Pere Test d. Elevations e: Water Table of -Aeal.th , Androv�r,MaSs DATE_________ ds . 10.2. 10.4 SUBSURFACE DISPOSAL DES10 CHECK LIST LOT DISAPPROM DATE_.:__-- Reasonss e submitted plan must show as a mdnimms the lot to be served-area,dimensions lot #sabnttera location and log deep observation ho es_di-stance to ties location and results parcolation tests -distance � leaching area design calculations & calculations sgg�i reserve�� location and dimensions of system-inc existing and proposed contours system or g) location any wet areas v$thin 100' of sewage disposal disclaiuer-check wetlands mapping () surface and subsurface drains Vi{bin loo' of sewage disposal system or disclaimer 1001 of sewsge disposal ('j) location any drainage easements ,thin system or disclaimer -Planning Board files 3) known sources of vater. supply Vitbin 200' of sewage disposal system or disclaimerlot-100' from leaching facility k) location of any Proposed well to serve location of water lines on property -10' from leaching facility (m) -location of benchmark n) driveways (gyp garbage disposals (p no pQC to be used in constructioni e septic tank, �) profile of system -elevations of basement, plumbspipes distribution box inlets . and outlets, distribution field piping and other elevations' -age . dispo sal --system w — ------ - - ( )" maground water. elevation -in-area- S" Engineer or other s) plan mist be prepared by a Professional Engin professional authorized by law to Prepare such plans L8S�;tic Tanks th of tees a) capac t es- 50% of flow, water table, tees, deP access, P�'Ping ) cleanout wad sing Pool ) 10, from cellar wall or ingro ) 251 from subsurface drains Distribution Boxes 0.08 ) s ope greater ) CIDP Form No. 3 Town of North Andover, Massachusetts BOARD OF HEALTH NORTH30 3: * ! OL (/ O p F DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSEt Applicant ADDRESS TELEPFioN NAME Site Location � ( � -- Permission is hereby granted to Construct ( ) or Repair (4-)-�ndi,idual Steil Absorption G Sewage Disposal System as shown on the Design Approval S.S. No. AIR AN,BiA;R�DOF TH �j Fee D.W.C. No. '- NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: 4 61 - PERMIT ## DATE RECEIVED / Z 1/¢ A - APPLICANT Jo"gu /-,?0005ji9 MAP PARCEL ADDRESS ## i ENG. STREET JF046e.0 -;7fU f9 O ADDRESS PLAN DATE I �G • A.4 �99-7� REV. DATE CONDITIONS OF APPROVAL APPROVED REASONS FOR DISAPPROVAL: DISAPPROVED iD -5E Z�Iq�j✓ �i , (.�gl Uwe /jjEEDEIj - ���s TN�A-' �` To ,21 yORTN o � p r Its HU Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 -D'C' -C' l 4 19� DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant .1QAwl J9tj,6 u r�Q Test No. Site Location 96 `-T b Reference Plans and Specs. • IiUFee.s C-- ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH Fee Site System Permit No. M� p PLAN REVIEW CHECKLIST ADDRESS �V UGI �.L� —IFP ENGINEER /GC �UT� SiV6 GENERAL 3 COPIES STAMP LOCUS 11K NORTH ARROW SCALE CONTOURS PROFILE SECTION BENCHMARK d C SOIL &, PERCS [/' ELEVATIONS WETS. DISCLAIMER — WELLS & WETS WATERSHED?./Vo DRIVEWAY �Elev) WATER LINE v FDN DRAIN SCH40,, TESTS CURRENT? c-� SOIL EVAL 5 • 37 -Pte_ SEPTIC TANK MIN 1500G ✓ .17 INVERT DROP c/ GARB. GRINDER(+200% EDF) 25' TO CELLAR MANHOLE 1---' ELEV GW # COMPS. D -BOX SIZE ## LINES 4- FIRST 2' LEVEL STATEMENT L� INLET OUTLET _ :/7 (2" OR .17 FT) TEE REQ'D? LEACHING MIN 660 GPD? RESERVE AREA _ 4' FROM/PRIMARY? 2% SLOPE 100' TO WETLANDS ^100' TO WELLS 4' TO S.H.GW (5'>2M/ ) 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY ✓ MIN 12" COVER v FILL? (t5' if above natural elev; 10'if below) BREAKOUT MET? �--- TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/1001) SIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501) BOT + SIDE X LDNG = TOT (L x W x ##) (DxLx2x##) (G/ft2) Copyright © 1995 by S.L. Starr PITS MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 660 GPD -,"""900 ft2 BED � GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? L-/4" PEA STONE?DIST LINE SLOPE .005? 4 >31COVER-VENT SCH 40_e� MIN 12" COVER i` RATE ZM W LDG . l X 660 = 16,00 X %¢ = TOTAL 740 G -/t -t-2-` _ REQ' D ( ft2 ) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = L W D Vol. DISCHARGE SIZE DISCHARGE RATE MANHOLES TO GRADE inlet) HWL OP. SWITCH Copyright 0 1995 by S.L. Starr ALARM SEP. CIRC. LWL CHECK VALVE PUMP CAPACITY Spm Spm DISCHARGE TIME GW (Min. 1' below BLEEDER HOLE MANUAL '!41) A, - Jt- t;uu�ttinN%teRif lt or hlasgnchusetts NJ©SSOCIMSOUS j�t�ltrvcct�e—S��siei�� nceiion o PA , 1 ��tr dr ru,r�t►it�N . firr,tir' 'ra„l•� �+�+ a Yes (:esspuul; hci , 1 cs t�! License a: Systertt Pumped by: Cuutents irausleired to: Unle ittSpeClUr TSN of RD of rapt all h Co tnlu 1wenlih of Mespechusclls •'ugsal;IlU561ig -- 5yslcnt Utvnet---- 5YAW—,,II�'u�t�Ning-1 cord ys(eut Loceliuti qe,-,U-0� Uaie of 1'urtq,ini;: Clueilmy !jumped: t' galldi�s y No ti ett (_.) !fiei i 1 / ila 'Tank; No) IJ YsM (,ceeltut+I: l'4� 5ysieui l'umiled liy: Vdt idd tglme 1wj ! License # Cn�ileuls Iteusle��ted lt� Qr stet �telleU �elll tY Ulsai�., �;,� -�� Dille: TOWN OF y- 'g -f" SYSTEM PUMPING RECORD DATE: 3 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED : CESSPOOL: NO YES SEPTIC TANK. NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIl-4) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste - 3 T33 GALLONS C Commonwealth of Massachusetts City/Town of System Pumping Record OCT 12 2006 Form 4 DEP has provided this form for use by local Boards of` Health -The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When wing out 1. System Location: on forms on the computer, use only the tab key Addres to move your cursor - do not Gity/Town �1 use the.-retum key. 2. System Owner: Name \J Address (if different from location) CityfTown Zip Code State Zip Code Tele -phone Number B. pumping Record 1 ate of Pumping —06 oate 2. Quantity Pumped. Gall ns 3. Type of system: ❑ Cesspool(s) 1JISeptic Tank ❑ Tight.Tank ❑ Other (describe),: 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of S stem: . V�cx A -4-a 6. Syste Pumped By Name Company 7 If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number (10 ---d -0!C, http://www.mass.gov/dep/Wat4r/approvalt,/t5forms.htm#inspect t5form4.doc• 06103 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of ' System Pumping Record 14 Hi9 Form 4 rowiv DEP has provided this form for use by local Boards of Health."" ed 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 Locati : Left fro�torear of house, n o R- -- �• W, right front of house, left side of house, right side of house, Left left side of buildinq, right rear of building, under deck. City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code Mate i code Telephone Number Date 2. Quantity Pumped Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Digo If yes, was it cleaned? ❑ Yes ❑ No 5. Conditionf S ste o �� � 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Loc on where contents were disposed: L Wwell Wa&te Water ler F5821 Vehicle License Number Date /a -f--`6) t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED a w° System Pumping Record Form 4 JAN- 4 2012 M TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forms .I 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 Locatio : 'Le Rig r nt of house Left / Right rear of house, Left / right side of house, Left / Right side of bul g, Left / Rig r of building, Left / Right rear of building, Under deck Address(� H') (44- 4--L� City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code State Zip Code Telephone Number Date 2. Quantity Pumped Cesspool(s) eptic Tank 4. Effluent Tee Filter present? ❑ Yes No 5. Condition f System: 611�C 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 7. Location a contents were disposed: . L,'S.'l _ Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record . Page 1 of 1