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Miscellaneous - 240 OLD CART WAY 8/20/2015
*NNdUSi ���rl����A���w,:• PUBLIC HEALTH DEPARTMENT Town of North Andover Cormnunity Development Division CERTIFICATE COMPLIANCE As of: 8/12/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair ox, Pipe and outlet tee By: Chad Jablonski At: 240 Old Cartffa Map 107B Lot 7 North over, MA 01845 .The Issuance of this certiti ate/gh'dt� of be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com 1 North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 240 Old Cart Rd. MAP: LOT: INSTALLER: Chad Jablonski DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: pipe d-box T 8/12/15 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX X Installed on stable stone base X H-20 D-Box X Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) X Schedule 40 PVC Pipe Comments: • k �� , Commonwealth of Massachusetts Map-Block-Lot r/��i�rr, � • 107.80117 BOARD OF HEALTH Permit No North Andover BHP-2015-0313 ----------------------- P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Chad-Jablonski to(Repair)an Individual Sewage Disposal System. at No -24-0--OLD--CART-WAY - r-bo Pp p -031 Dated July 1_--2015 as shown on the application far Disposal Works Construction Permit No. BHP 015_ a -------------------------------------------------- Issued On:Jul-17-2015 BOARD OF HEALTH R, Application for Septic disposal System TODAY'S DATE Construction Permit — TOWN OF $ Full Repair NORTH ANDOVER, MA 01845 $125. - omponent Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key Repair or replace an existing system component—What? to move your cursor-do not use the return A. Facility Information key, `�� .. �'1cJ 6) °" u Address or Lot# tab j I i City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ff Gravity(choose one) ***If pump sy em, attach copy of electrical permit to application*** ➢ aConventional 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. A ❑ 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? What is the Model. 2. Owner Information Name Address(if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information Name Name of Company Address Cit y/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 f SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: address of septic s stelm For plans by Relative to the application of \ (installer's name) And dated rigtna.date) Dated t� � With revisions dated (Last revised(la e) 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 rp for to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (1S) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OIL (or e-mail to: he;tlthdeiat&,towrio riortlxatidover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the .rand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: / _ (:l'oday's Date) ^r (Name—Print) C� (Narne— Signed) I "N. App lication for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $250.00—Full Repair NORTH H A DOVER., MA 01845 $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. Name Date s Ja Iic,aLnA' prbv e 4yt(Boar'(of Health Representative) , . a . me w.. Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached? YeS11 No 2. Pro'ectMana er Obligation Form Attached? YesV No 3. Pump System? Ifso,Attach coj2.y ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received. Yes No Missingl 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) G. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 %AORTH w• BUILDING PERMIT �$ g 1 p� TOWN OF NORTH ANDOVER ® : APPLICATION FOR PLAN EXAMINATION I gyp Permit NO: Date Received_ ��SSACHUSE�R Date Issued: IMPORTANT: A2pficant must com fete all items on this page LOCATION T ' Print OROPERTY,'OWNER , MAP JN0; PARCEL: ZONING DISTRICT:, Historic District yep q; MachineShop Villa yes a ^� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ N w Building ne family dition El Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ D molition ❑ Other { e' t�c0'Well ❑'Floodplain 0 Wetlands ❑ Watershed District o Water/Server A1/ -tJ t , .. r&.1 Identification Please Type or Print Clearly) DWNER: Name: Phone Address: D °' ` aiw COhYT,RACTOR ,Name ; _ � Phone, '9' .,4 / /r �/i �iif% obi f //� Su enr�sor's ans# ucEic►nLicen'se Exp Date Home Impro�emen �ICense„ Exp Date: 'i ARCHITECT/ENGINEER ,- Phone: 7/11— Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ No Coo, - FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fiend Signature of Agent/Owner � Signature of contractor Mans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans [] TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ --____--' Well Ta �assageBodyA� E] SwilniningPools ❑EJ Tobacco Sales ❑ Private(septic tank,etc. ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF ® U FORM PLANNING � DEVELOPMENT Reviewed On . ---____.__ Signature COMMENTS CONSERVATION Reviewed on J � Si nature � oM COMMENTS �,7 HEALTH Reviewed o Si nature COMMENTS r r Aa to Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted es y Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/shoat ire& Date Drivewa Permit DPW Town Engineer: Signature: FIRE ®EP,,�►RTMENT Lo Temp Dumps on s sgo Street ter Gated at 124 Main Sfireet ti ite ,yes Located tno O ,6 od t , Fire�Department:�igr�a�,�nre/ " K date ', j a COMMENTS p10RTN BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ ti ,rmit NO: Date Received d R cna.nf�w�<m a? gO�A7e° ate Issued: �SSACHU5 IMPORTANT:A2plicant must complete all items on this 2age r ROPEF� " U1/NER i� ii PARCEL: ZONING 1 ` ge ye istc Ds �ct M chine Sho p la ye � 'PE OF IMPROVEMENT PROPOSED USE Resislential Non- Residential I New Building &One family 29d ❑ ition Two or more family El Industrial d 1teration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: 1 D molition ❑ Other j��� ,p rc r ell O Floodp)aitt I f Q�Wetlarids� � e � , ❑ UVatersh d District e /�/ ii ✓ '*I , ! J/ "t" Identification Please Type or Print Clearly), y), ER: Name: Phonec'\ - °t" ss Name '; 6 )N�RACT Phone' /� i/i/ i /r / i j lrr /,i/,/ //,/l/i!/ ri�o.. ,ar/ .✓ ,.,���r/�tJ'o nstru4✓ �, � gyp, Fran Lrcens �,i�/,/,%%I//,�. ��i ,,,,,,r ✓// „" „< s ,EX�y i Dater , /i i /i//r i //% /r/ //� / //�/ iii✓//� i. i i„ // �n,,,,,mparouemen�License.. r �� ;, 10" ,xp ..Dot 'CH ITECT/ENGINEER Phone: / II; dress: A ! Reg. No. FEE SCHEDULE;BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. 7 tal Project Cost: $ ` 6' FEE: $ eck No.: Receipt No.: i ITE: Pei-sons con tl acting with unhegistered contractors do not have access nature of A ent/Owner g Y fund I ' to the rcarnt g ature of contractor t f CI) ID s ; �:> .• i I T �.• i � � n o m � Harty porch & Renovation 240 Old.Cart Way,N.Andover,Ma 01845 pI -13-2015 1/8"=1'0°or noted Existing Plans Mark Wagner-Architect 6 Malcolm Road Cambridge,MA 02138 617-661-7176 markwagnerarchitect @gmall.com T, 3 I I I • I I I , U I I I I , I .I I I -- a I � I I p l I I� i ' I I Harty Porch & Renovation 240 Old Cart Way,N.Andover,Ma 01845 ® 1 -1-3-2016 1/8"=1'0"or noted Existing Plans Mark Wagner-Architect 5 Malcolm Road Cambridge,MA 02138 617-661-7175 markwagKerarchitect @gmail.com II 'I li II p6 I I r � . d I I li I II iy I I + m i c j ❑ r ii � li w I, M I. v n u M fi El 'I 1� I� i' I � . I � Harter Porch & Renovation 240 Old Cart Way,N.Andover,Me 01845 1-13-2015 1/8"=1'0"or noted ® Existing Plans Mark Wagner-Architect 5 Malcolm Road Cambridge,MA 02138 697-661-7175 mari<wagnerarchitbct @gmail.com , m i d 'r h1 X • Q t .. J ty �lW m t o AaN FIrLM I '.. BnT dot.CTS S z ' 3 b I f4, N O 3 - o I � 1 CJ Z 1 Harty Porch & Renovation 240 Old Cart Way,N.Andover,Me 01845 ® 1-1,b-2015 118"=1'0"or noted Existing Plans Mark Wagner-Architect 5 Malcolm Road Cambridge,MA 02138 617-661.7175 markwagnararchifact @gmaiLcom wog pBwB�paUU�181euBermPew sitz-l99-L49 8£420 VW'aBpUgwaO peob w1031E, 9 49aa!4�rd-aau6e/y►�JaW sued uo�=.V/; uo� paaouloa0,4=.4/4 54pZ- 54840 8W'lenopuy`N'FeM3180 PIO ObZ uol;enou®}I V yoJOd BH I � / d. im 2 QL z-Z H aa�_ CL 3 I 3L I y- 0-� w`�1 z4) CL � I ' 3 B z � � s Z Ox 2. � z 0 0 ra_ 0 ° d C" O l�1 O O O 0 W �o F9 N H m m .-...-_,I ._. HEF Z v u ///JJJJ __1 .I 1 1 1 I I I I i I � I 1 I � I 1 1 1 I _ I 1 N - 1 1 I I CW 1 I 1 Q trr I— x I –Nt I 7- Z 1 3 Ro Y W I m0m I m 0 I O i I i d C N z • a x Rio °y �a N p � I @ S X I 4•£ G A, o G- K" P - 3!t2v m w Jam,it\ I Ha r rtv Porch & Renovation 240 Old Cart Way,N.Andover,Ma 01845 ® $-l -2015 1/4"=1'0"or noted Construction Plans Mark Wagner-Architect 5 Malcolm Road Cambridge,MA 02138 817-881.7175 markwagnerarchitect @gmail.com Commonwealth of Massachusetts Title 5 Official Inspection r Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1° 240 Old Cart Way Property Address Hart Owner Owner's Name information is MA 01845 5/18/2015 required for every N. Andover page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms . on the computer, M/.4 • �. ' use only the tab 1. Inspector: key to move your 0 tq OF R'4Of'TH NE)OVER cursor-do not Chad Jablonski C rte ' ,'.M NT use the return Name of Inspector key. C J Jablonski Septic Inspection and Repair rQ Company Name 237 Merrimac St. Company Address , Newburyport MA 01950 CitylTown State Zip Code 978-360-9358 4574 Telephone Number License Number B. Certification 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 ❑ NeedswFurther E aluation by the Local Approving Authority In pertor-s'8ignat re Date The syste, 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Ij Commonwealth of Massachusetts Title 5 Official Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 240 Old Cart Way Property Address 1' Harty Owner Owner's Name information is required for every N. Andover MA 01845 5/18/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title Official Inspection r Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^„ 240 Old Cart Way Property Address Hart Owner Owner's Name 01845 5/18/2015 information is N. Andover MA required for every City/Town State Zip Code Date of Inspection page. 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 Z N ❑ ND (Explain below): ❑ Y ® N F] ND (Explain below): obstruction is removed ❑ ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box needs to be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 15ins•3/13 Il Commonwealth of Massachusetts it f Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 240 Old Cart Way Property Address Hart Owner Owner's Name MA 01845 5/18/2015 information is N, Andover Date of Inspection required for every State Zip Code page. CitylTown 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 welnWand the presence of ammotniaDnErogeniandlnbrate nit fecal equal coliform bacteria indicates able p Bred. A co of the analysis must to or less than 5 ppm, provided that no other failure criteria are trigg copy be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of 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 in due to an overloaded ❑ or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 t5ins•3/13 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 240 Old Cart Way Property Address Harty 1 Owner Owner's Name information is required for every N. Andover MA 01845 5/18/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If 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. I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 240 Old Cart Way Property Address Harty Owner Owner's Name information is N. Andover MA 01845 5/18/2015 required for every page. City/Town State Zip Code Date of Inspection C. Checklist 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): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts F Title Official Inspection Form Subsurface Sewage(Disposal System Form- Not for Voluntary Assessments °�M ,•°''v 240 Old Cart Way Property Address Harty Owner Owner's Name information is N. Andover MA 01845 5/18/2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 5 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Attached 9 ( Y 9 (9p ))� Detail: Sump pump? ® Yes ❑ No Last date of occupancy: oOceupied J Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form- Not for Voluntary Assessments iAIA, 240 Old Cart Way Property Address Hart Owner Owner's Name MA 01845 5/18/2015 information is N, Andover required for every City/Town State Zip Code Date of Inspection page. D. System Information (cant.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Home Owner Source of information: Was system pumped as part of the inspection? ❑ Yes ® No na If yes, volume pumped: gallons na How was quantity pumped determined? na Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 t5ins•3/13 i j Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 240 Old Cart Way ' Property Address Hartytr Owner Owner's Name information is N. Andover MA 01845 5/18/2015 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) 1 Approximate age of all components, date installed (if known) and source of information: Soils test performed 10/13/1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 40" below top foundation Depth below grade: 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.): Watertight at foundation Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) na If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10.5 x 5.5 x 5.5 Dimensions: 51' Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts d W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments I 240 Old Cart Way Property Address Hart Owner Owner's Name 01845 5/18/2015 Andover information is N. A MA required for every City/ ndo State Zip Code Date of Inspection page. D. System Information (cont.) Septic Tank(cant.) 30" Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" measuring tape How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was structurally sound. Outlet baffle needs to be replaced. Liquid level was 0" above the outlet. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 t5ins-3/13 Commonwealth of Massachusetts i itl Official In p tin r Subsurface Sewage Disposal System Form Not for Voluntary Assessments n, 240 Old Cart Way Property Address Hart Owner Owner's Name MA 01845 5/18/2015 information is N. Andover Date of Inspection required for every State Zip Code page City/Town 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: ❑ fiberglass F-1 polyethylene El other (explain): ❑ concrete ❑ metal Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm in working order: ❑ Yes E] No Alarm level: 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 Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 17 15ins•3/13 r Commonwealth of Massachusetts r Title 5 official Inspection r Not for Voluntary Assessment s a Subsurface Sewage Disposal System Form- 240 Old Cart Way Property Address Hart Owner Owner's Name MA 01845 5/18/2015 information is N, Andover State Zip Code Date of Inspection required for every City/Town page. D. System Information (coat.) Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert evidence of solids carryover, any Comments (note if box is level and distribution to outlets equal, any evidence of leakage into or out of box, etc.): Box is corroded and needs to be replaced. pump Chamber (locate on site plan): ❑ Yes ❑ No* pumps in working order: ❑ Yes ❑ No* Alarms in working order: 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 17 t5ins•3/13 Commonwealth of Massachusetts Title Official Inspection Form Not for Voluntary a Assessments Subsurface Sewage Disposal System Form - 240 Old Cart Way Property Address Hart Owner Owner's Name 01845 5/1$/2015 information is N. Andover MA required for every City/Town State Zip Code Date of Inspection page. D. System Information (cant.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 3-70' ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of hydraulic failure or ondin . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t5ins•3113 Commonwealth of Massachusetts Title Official Inspection r Subsurface Sewage Disposal System Form- Not for Voluntary Assessments „.H 240 Old Cart Way Property Address Harty 1 Owner Owner's Name information is N. Andover MA 01845 5/18/2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title Off i i I Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 240 Old Cart Way Property Address Hart Owner Owner's Name information is N. Andover MA 01845 5/18/2015 required for every Cityrrown State Zip Code Date of Inspection page. 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 .. .I t� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 t5ins+3/13 Commonwealth Massachusetts . — 'tNe 5 official @nspec/tmon Form | [� o N tforVo\untaryAennaemenre Subsurface � ' Sewage ispoeml Syolmnn ��rmm- 240 Old Cart Way Property Address Ha Owner Owner's Name 01845 o/ /o/cv'^ information is .,.. required for m evo ''� � ' page. ' k��Ot \ K�, 00 8nfm'r��at0��KV ,-- , Site Exam: Z Check Slope Z Surface water Z Check cellar �� Shallow vveUa .� 92, Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: �� {) nn Obtained plans on nanond �~ 10/13/1880 \f checked, date of design plan reviewed. ----------�Date � F1 {]boorvedsite (abu#ingproP*�v/obeamationhole vvhh\n150 feet o|SAS) �� � l Checked with local Board of Health- explain: �� �� {}heokedwhhlocal excavators, \nstaUern' (m�enhdocumentation) ,� � l AooeneedUSGS database - explain: �� you must describe how you established the high ground water elevation: Soils test performed 8/13/1986 b R.Mas s and witnessed b M. Before filing this Inspection Report, please see Report Completeness Checklist om next page. Title o official inspection Form:Subsurface sewage Disposal System^Page,om`r 15ins 3/13 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 240 Old Cart Way Property Address Hart Owner Owner's Name MA 01845 5/18/2015 information is N. Andover Date of Inspection required for every State Zip Code page. City/Town 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 t5ins-3/13 Page summary Record Card generated onan9/2ms3:2emmoby Maureen McAuley Town of Andover � ` '-'' ��- ff ��� ��� K�_���������.� � ]���� ,"°��8� ., ~~ °�~ ^=" ^~��� ^ ° " ~~�- - ^ Parcel \d 18227 240 OLD CART WAY HARTY, PAUL 240 OLD CART WAY NORTH ANDOVEFl, MA 01845 Property Type I�Residential 101 single Family Zoning3 I Residential Class size Total 1.08 Acres FY 2015 Until AnUw�|nmm. From rYP» Name/Address Payor HARJY,PAUL u40 OLD CART WAY NORTH ANDOVER,MA 01845 Au�)vu/\nwnt\vu Cycle occupant Name oe�oi||ingoa�a5/0�O15 Active CCOU ~~~~-n''- 2O 240OLDCARTVV�( - Bldg Id �o7u � ' aint. � � Cycle O1 01 1O9O*3o Account No. 1O«O43» Rate 7.82 multiplier/Users yomiomoodo 80 T.82 v M\8CFEE8DM|NFEE O'035�LL�ETERG|2E 53.:0 VVTKVVATEn Type_ Size YToCvnm Account No. 1090439 Brand 789 Serial No Status Location b oouQer _Water O.O3O.83 Variance 32772770 a8dkm UO Consumption Posted Date -42%Date Reading Code '` 5/19/20 ~'- 4/27/2015 1UgV aAdua| " 2/20/2015 ^"~ 1/30/2015 1070 aAdua| 5" 11/14/2014 165~ 10/24/2014 �U48 o�c�� °2 013/2014 `^° 7/25/2014 988 aActuw 15 5/15/20 14 21% 4/24/2014 857 eActual 18 2/14/2014 -2% 1/27/2014 942 aActua| 15 11/102013 -1V, 10/23/2013 923 aAotual 15 01512015 -12% 7/23/2013 900 ^Actua| 15 5/20/2018 -65% 4/24/2013 833 aAct«u| 18 2/13/2013 '14% 878 uA�«o| 51 11/9/2012 168% 10/23/2012 axdua| 59 8/14/2012 29Y6 10/23/2012 on9 eAdua| 22 5��U12 57�6 7/2�/2O1u 750 aA�uo| 17 2/13/2012 '33Y6 �z��O12 728 oA�ua| 41 11/1�2V11 ' 4'� 1�S�O�2 711 aAo�� 17 8/15/2011 -6%10/24/2011 o7O aAdu� 1T 58O�O1 �4% T�2Q011 � 553 oAc�a 20 2U1�011 121'� 4��2o11 _ 1/25/20'1 836 a Actual 75 11/12/2010 03% 616 aAcm� 33 01�2U1O 106 1N2»20�O 543 uAn�e| 18 5/1z�n10 -34Y6 7/22/2U1O 510 aA�ua| zn 2/1�2O1V '9O"� �zzmO1O **2 oAo�u| 30 11/11/2009 1196 1�1�O1» 472 aAdua| 18 01�2»»S ''3`� 10o2QOU8 442 aAuma| 18 5/13/2009 -25%7/x4/oOoe 426 aA� ' Actual 10 Z/1O/uO8S 43Y6 4/24/2009 9 408 u8d 'wa| 25 11/1o/2nO8 2O'� 1/23/2OU9 88e aA�ua| 40 8/15/2008 0 0%1O/n�/»OO8 384 aAmua| 18 5/19/2008 7/zo/zOU8 321 oA�ua| 4/z3/2OOn TOWN OF NORTH ANDOVER o� ytoWTH �a a VICES Office ()t C,0N/1 1UN '1'Y EVEL ( PNIE t AND SC ° H EE LT I.1 DEPARTMENT �( 7 d DS I T NORTH ANLCY �1, 'r "anrn °a lh s MASSACHUSETTS 01 845 cHus 978.688.9540—Phony* Susan Y. Savvyer, REHSfRS 978.688,8476—FAX Public Health Director ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION LOT: FOR q ADDRESS: INSTALLER: DESIGNER: PLAN DATE: o L BOH APPROVAL DATE ON PLAN: ' INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: .. C SITE CONDITIONS 411 H�N -ing septic tank prod Int rnal plumbing all to c , ❑Topography not appreci; "° '"°° Comments: SEPTIC TANK ❑ Bottom of tank hole Weep hole plugged [] 1500 gallon tank ha .. H-10 loading Mont ❑] Water tightness of tE f (Visual or Vacuum -I cat vi v vatci i 1ciu iur Gott ii�j F-1 Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER �ya oit7H , ?p teo ;°rr�0 1 1 DEPARTMENT a Yn V Offlee ()9�;"O�it�fUNITY DEVELOPMENT A1��� �L�Vt � � HEALTH 400 OSGOOD STREET °? '` ot�" NORTH ANDOVER,MASSACHUSETTS 01 845 978.688.9540—Phoue Susan Y. Sawyer, ICE}4S/RS 978.688.8476—FAX Public Health Director Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading ° Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ pump(s) installed on stable base ❑ Alarm float working ❑ pump On/Off floats working ❑ Separate on/off floats ❑] Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved. Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENTTECH.NyOpe of ❑ treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVERp��,��7w ()ffice of C:OaVtMt.1i YTY DEVELOPMENT AND SE RVtC ES 0 p FIEALTH DEPARTMENT 400 OSGOOD STREET Y° NORTH ANDOVER, MASSACHUSETTS 01845 SA-H���� 978.688.9540—Phorte >usau Y. Sawyer', REHSf1tS 978.688.8476—FAX Public Health Director D-BOX ❑ Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided.(not required) Comments: SOIL ABSORPTION SYSTEM w Bottom of SAS excavated down to oil layer, as provided on plan ize of SAS excavated as per plan ED----Title 5 sand installed, if specified on plan �/4-1 1/2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: , 7 .. Wastewater System Documentation—Feb 2006 Page 3 of 6 TO l d OF NORTH ANDOVER . , , 1� p1CiRTN Office of COMMUNITY DEVELOPMENT AND SERVICES' HEALTH DEPARTMENT 400 OSGOOD STREET °�`•-:-M '7' w6Anreo nrw ,% NORTt] ANDOVER, lu1ASSACHUSETTS 01845 CHU`✓�� Susan Y. Sawyer,REHSIRS 978.688.9540—Plhone Public I lealth L)irector 978.688.8476 _FAX PRESSURE DISTRIBUTION ❑ -- inch manifold laterals installed with end sweeps . size: material: Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation—Feb 2006 Page 4 of 6 ORTH TOWN OF NORTH ANDOVER q�{,gun rap't'q Office of CONIMUNI"I'Y DEVELOPMENT NT AtD SERVICES HEALTH DEPARTMENT 4 , a Ctl*4 1:k'M 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 .wcwus� 978.688.9540—Phone Susan Y. Sawyer, REI1S/17S 978.688,8476—FAX Public I lealth Director CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer [❑ Property line 10 10 ❑ Cellar wall 10 20 ❑ Inground pool 10 20 E] 5 10 Slab foundation 10 ._ ❑ Deck, on footings, etc S 10 10 101 F] Waterline 1002 50 ❑ Private drinking well 75 F-1 Irrigation well 75 100 ❑ 25 SO Surface Water ❑ Bordering Vegetated Wetland 100 Salt Marsh, Inland/Coastal Bank3 75 ❑ Wetlands bordering surface 150 water supply or trib. (in Watershed) 150 325 ❑ Trib.to surface water supply 325 ❑ Public well 400 400 [] Interim Wellhead Prot. Area 400 400 ❑ Reservoirs 50 100 ❑ Drains (wat. supply/trio.) 50 ❑ Drains (intercept g.w.) 25 ❑ Drains (Other)Foundation 10(5) 20(10) ❑ Drywells 20 25 C per. Suction line 222(2) 2 . 2 100 feet is a minimum acceptable distance and no variance is allowed tiors es e Idistance(also by NA wetland s As defined in 310 CMR 10.55, 10.32, 10.54,and 10,30,respectively,p bylaws Wastewater System Documentation—Feb 2006 Page 5 of 6 TOWN OF, NOR'I'H ANDOVER rF,I'.. ES ivIEN'r AND SERVIC Office 01'COMMUNITY DEVELOP to , REAMI DEPARTMENT 41 q 400 OSGOOD STREET NORTH ANDOVER, NIASSACHUSETTS 01845 C" 978.688.9540 Pilone Susan Y. sawyer, tZEFIS/RS 978.688,8476 FAX Public I jealth Director* SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral I HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Wastewater System Documentation Feb 2006 Page 6 of 6 TOWN OF t OR'T H ANDOVER O..Ra Irw tiOfice of C OMMUNI TY DEVELOPMENT AND SERVICES o� HEALTH DEPARTMENT 400 OSGOC)D STREET 41 NORTH ANDOVER, NIASSACHUSETTS 01845 spa4us Susan Y. Sawyer, REHS/RS 978.688.9540— Phone Public Health Director 978.688.95,12—FAX December 8,2005 Paul&Sarah Harty 240 Old Cart Way North Andover,MA 01845 Re: 240 Old Cart Way—Proposed Septic System Expansion Dear Mr.&Mrs.Harty: The North Andover Board of Health received your plan titled;"Proposed Septic System Expansion for Property at 240 Old Cart Way,North Andover,MA"dated December 5,2005,and received by this office on the same. The design has been approved for a five(5)-bedroom,maximum 11-room home and is to be used in the construction of an upgrade onsite septic system.This approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed by the installer,designer and the Town of North Andover. This approval is subject to the following conditions: 1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void, installation shall stop,and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 2. It is the responsibility of the applicant and/or the applicant's septic system designer,septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission,Zoning Board, Planning Board,Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please note that the septic installation season closed on November 30,2005. Per your agreement to complete and update all of the changes necessary to the current septic system as a condition of your permit for this year,and notarized here in our office on December 7,2005,you understand that a licensed and registered contractor will do the work as quickly as the law and weather permit in the spring of 2006. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincerely, . '..- Susafi Y. Sawyer, REHS/RS " Public Health Director Encl: List of licensed septic system installers cc: R.A.M. Engineering, 160 Main Street,Haverhill, MA 01830; 978.372.0449 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 2W O ',9L_-o C,A'_.r WA t'k relative to the application t.Ir"�r'�.r."� of���+� '�� dated for plans by P. M , DVG �Nj and dated I Z- 0 7 '`) ' with revisions dated 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 prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. with pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersign d Licensed Sept' staller Date: "y C7'`1 r ` YY1 r 0 � �4... i 4 VIC r r ,ar Applicat! >n r tic Disposal System __ ❑ "•.�ONI ly �„p TODAY'S DAT� Construction Permit - TOWN OF 4 ' . u T 184 $...250.0®—Full Repair � `> ° $125 Ofd°pC�.omponent Ai:rl 1f. ,wm Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use Repair or replace an existing on-site sewage disposal e' m* only the tab key ❑°Re aito move your r or replace an existm g s stem component cursor-do not /❑ ❑ key. A. Facill$y�Information u ° ❑ � ❑❑ use the return rab Address or Lot# enan City/Town — ------ — 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiff user(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information / A L.L. /w SGc rr, Name L�D CAl r' � � ` — Address(if different f m above) r City/Town State Zip Code Telephone Number 3. Installer Information �w+ l"= //"// - -_-Ik f°l Name Name of Company ❑ Addr is City/T wn State Zip Code Telephone Number(Cell Phone#if possible please) a. Designer Information !� Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit Page 1 of 2 i Application for Septic D t TO ----- DAY' DAT �X onstructian Permit NORTHTIC®► I�I�A, 0145 ®0_Full Repair - 12 Component PAGE 2 OF A. Facility Information continued.... 5 YM I a of Buildin esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been is ed by this Board of ealth. f Na Date Applica Io Approved B .,(Board of Health Representative) Date Application Disapproved for the following reasons: For Office Use Only: _____ Yes `" No 1. Fee Attached? — Yes No 2. Project Manager Obligation Form Attached? L-" — 3. Pump System? If so,Attach copy of Electrical Permit Yes__ � .-- ` � No____ 4. Foundation As-Built? (new construction ronl Yes— ,-; No (Same scale as appromd plan) Yes , �,r No 5. Floor Plans? (new construction only): — Application for Disposal system Construction Permit Page 2 of 2 TOWN NORTII ANDOVER Office of"COMMU I` Y µ D1�VELO M ANI) SERVICES E .LT'F� .DEPARTMENT' jy/rPryyAR EN ' y p) [td5 NORTH H AMXW I�, MASSM,JUSI.y.t l S 0 184 978.688.9540 _Mime Susan Y,Sawyer,REHS/RS 978.6M8476- FAX Public Health Director }:,AlAiL healtlsc{��t�rztc;��vz�ca�ryc�rtlr<z��rlovt� cc>ttr. WP BSl]' littli,.//Nv�N+w.t4rwtiof'�ic>t_tl siirlc�ry r.coi .- . SEPTIC PLAN SUBMITTAL FC►R$1✓I RECEIVED t ° 1 w. Date of Submission: t�',.��� Z..- � E ,i Site Location: �w °7 _ ') �,,.. .,, �`����N O NORTH ANDOVER lIt.:/'at.:ttt DEPARTMENT Engineer: (�.A). ( A- y New Plans? Yes $225/Plan Check# (includes I"submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes V, No Local Upgrade Form Included? Yes No Telephone#: 4'y9 Fax#: J t E-mail: ( , G Q oA .co el,- , . Homeowner Name: I OFFICE USE ONLY When the submision is complete(including check): ➢ , /s Date stamp plans and letter F� ➢ � ` Complete and attach Receipt ➢ Copy File;Forward to Consultant ➢ kr Enter on Log Sheet and Database 0EC 0 4 20 zl 0 H ANDOVER HEALTH DEPARTMENT ❑ ❑ ❑ 2 Z Z a„J o 0 a Z n 6 ❑ ❑ -a) r a m o m Q ® CL � � m a, z m cn � o r• U) 0 ( m ❑ �? 4i a M C tJa CL o ID a E o •W a 5 z z ro ... a ca a E CSC ❑ °7c =_ -_ d N-9 B C N y < C O �■� CL CL ® o ® cn !D ^^mp z Z r *1 Ids W ca � u E cv 4) o' ® o ° w CL CL LO CD "7 "Q ta 6 E El ❑ °' °' ro O o e` 5 c oc CL d v •° + ' U y Q °o fl S Q '® o m a) o G o ca = o ?' ro m $ 4m 5R us E 5 C ® m E o c �C 3. 9 0 z ar > 5' m o s li O vy U UMW d to ti U O i j w a ,.✓ a `� aE w h (D �i a 4V p N C 1�1 t0 z° ® a U VVV ¢ O a a a ro CL p ® m N 41 `° IL li a�i ° w t0 c CL W U�Qj n.7 (D C13 (� Q w D o as O O d C a ®a °ar CD CD o 'S e rn CL E ».o a. a d U. 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W .� a 0 CL C- _ ® c gmL. ° ri , 1.__.- f , a = To c ro w ^h i TO�VN OF NORTH ANDOVER ORT '100 i 1 b Office of ✓OiMM ti JT Y LV11O IME SFMV IC S B HEALTH DEPARTMENT 400 OSGOOD STREET yyORT Y ANDOVER, TTUCEyyS 01845 ► a "MS«a �p� $usan Y.Sawyers d ERS,R� 978,689.95412-. Phone Oubli+c Health Director 978.688.8476 ;,.FAX ' • healxixde�tl aktov�ms�"r+ar�lxando•ves.cos�s www.tovmofmorthandover.cnm API�LICA'I'ION FOR $OIL TESTS DATE: 11/17105 MAP 4, PARCEL: 107B-27; tCIckno.I;o. SOIL TE3x5; 240 Old Cart Way OW 1k Paul&Sarah Marty contact 978-372-0449 APPLMANT: Paul&Sarah Harty contact.#: 978-3t-0449 ADDRESS., 240 Old Cart Way .FI!1+GTN"MR.,� Robert A. Masys, P.E. Contact:#: 978-372-0449 CE11,71FT,ED SOTL LVALUATOR: Robert A. Masys, P.E. Intended Use of Land- Residential Subdivisio-n Single Fsimsly HarnG� Commercial is_Th:lss :Repair•Testing,-_ Unt oycloped Lot Testing;i Upgrade for Add9tiort:,._X_ .. In the Lake Cvchic wwick Watershed? "Yes 'No X THE POLLOWTihiiG MUST 811 JNCLUDED WY"Skx T.RIS poRM Proof nirland t,wneralsip(Tax bill,or letter*om d"orpormitiang test) > 8.S"':11°'Plot Nan&F,ocai Ieme i ate fog it sM1.9 hn the Lama r Fee of n42 qd per lot for n,,;,., v comatructiaix. 7169 covers the rninimtntt true deep lioleg and two peredlation teens required for eanh disposal area, Fee of MO.00 per lot for renaim r► uggts Rg. GENERAL Tl41FORMA TION Only twertitied Soil Evaluators may Perform deep bole inspections. A Only Mass,Registered Sanitarian i and professional Engineers can design,septic plans, At laaat two deep holes and two percol"atio,t tests are required for each septic system disposal area. )4, Acpairs require at bast two dacp holes and at least ane percolation test, at the discretion of the B014 representative, > Full payment will be.required for all additional tests within,mvo weeks of testing, * .WitbIll 45 days.of testing,a,scaled plan (no smaliar than V-1 Od')shall be submitted to tho Board ofklealth showing the Jocation of all tests(is,cludirtE aborrodtests). W'tlxin 60 arty'Of testixxg sail evsaluatton form's shalt be submitted, Please Do Not'Write Below This Line co"Ye7vadoll cas"Mission Appra1NJi,T aym Slvrtawre of Conversation ation Agent. ,pate back to Health Dctpargmemt; (jta»zp ir�1- is used to verify that all necessary approvals/permits from INSTRUcTIONS-. This form ction have been obtained. Thii-dor�s not relieve Boards and Departments having jurisdi and/or landowner from compliance with any applicable or requiremen t s the applicant a APPLICANT FILLS OUT THIS SECTION' PHONELt�I APPLICANT LOCATION: Assessor's Map Number-!. � Q PARCEL.L_��,� LOT (5) SUBDIVISION ST. NUMBER� STREET OFFICIAL USE ONLr:": ***�� REPOM EN- TIQNS 0F,TQ , N AGEN N MIN ST R DATE APPROVED CO ER AT DATE REJECTED COMMENTS—'�� DATE APPROVED TOWN PLANNER DATE R tEtl- EJEe COMMENTS DATE APPROVED FOOD INSP CTOR-HEALT I DATE REJECTED - DATE APPROVED s PTIC IN PECTO -H LT1W DATE REJECTED z" COMMENT J PUBLIC WORKS -SEWERrWATER CONNECTIONS DRIVEWAY PERMIT ,,,"`FIRE DEPARTMENT r "ECEIVE n BY BUILDING INSPECTOR___� RovIsed M97 IM To the Health Department and Building Department of North Andover, I, Maul Harty owner and resident of 240 Old Cart Way, North Andover MA 01 845 certify that I will complete and update all of the changes necessary to the current septic system as a condition of my permit for building the addition as submitted on November 1, 2005. I have been advised by a certified Title V engineer and am -aware of the changes necessary to have nay residence in compliance with the law. A licensed and registered contractor will do the work as quickly as the law and weather permit in the spring ui -20-01. . Paul Marty 240 OidCartWay North Andover Ma 01 845 07 v DONNA M.WEDGE INIMARY PUBLIC COMMOMATH OF M ASSACHUSE M My Comm Exphw Aug.7,2009 i L O-r _ °♦♦ ♦♦Fes• ♦ ♦• ?�� }�y� •��°9.i.,..,_.,_ ...any\a�� '�`� .��y� i I-k le 9 OF 1o%< / SEPTIC . . YAT AS T A W AS PAGE. ►l? �� 7;?C G AP � vs MAXt eoAOI SltWXT p v YI fJ [ a CONS DESIGN REMODELING SOLUTIONS 1 $),AM 4 2' IMA Town of North Andover November 17, 2005 Board of Health Department 400 Osgood Street North Andover, Ma Phone: (978) 688-9540 Fax: (978) 688-8476 Re: Harty Residence 240 Old Cart Way To Whom it May Concern, I would like to provide your office with the necessary documentation you requested to move forward with the permitting process for the above residence: I, Jeffrey L. Ward president of J. L. WARD CONSTRUTION INC; acting as the duly appointed agent / representative for Paul and Sarah Harty of 240 Old Cart Way North Andover Ma have retained the services of Robert A. Masys, P.E. of RAM Engineering, 160 Main Street Haverhill, MA. 01830. Mr. Masys has been retained to perform the necessary requirements associated with the Septic expansion/upgrade, which is required as part of the permitting process for the proposed addition. Thyknda be t re arils, Je and — President J. L. Ward Construction, Inc. Design and Remodeling Solution Enclosures: Proposal # 100605 Construction Agreement November 17, 2005 To whom it may concern: I give permission to Robert Masys of Ram Engineering to perform a septic consult at 240 Old Cart Way in North Andover Massachusetts. If you have any questions please cal me at 978-794-1106. Sinc ely Sarah Harty 1 fi . . '� �, '.6."`�< �• ox Cam, �� a. .� � .. • � .,.µ ,n tin r-.. N' i F a— (IS F�l Cj-u a ; ;► w y ► a ��� ` s2�'re,' -- ., TAI •(y� S <<c� �r�yL.� ��� Z f F PLAN REVIEW CHECKLIST I ADDRESS / °"m ... " ENGINEER GENERAL 3 COPIES STAMP " LOCUS t. NORTH ARROW SCALE -z be SOIL & CONTOURS �''��-�"�." PROFILE ��."-~'°" SECTION BENCHMARK ,,e t- PERC INFO--L-1---1 ELEVATIONS °°""" WETS. DISCLAIMER l.,,, WELLS & Elev WATER LINE I� -~ WETLANDS WATERSHED? 1) DRIVEWAY ( ( ) FDN DRAIN t_ SCH4 0 TESTS CURRENT. , a � x SEPTIC TANK . 17 INVERT DROP: GARB. GRIND (+2000 EDF) MIN 1500G. t�-"�°��. C; � �a,�•. 25' TO CELLAR " MANHOLE TO GRADE ."-'' ELEV GW _D-BOX LEVEL STATEMENT ,,----""- SIZE �..��1..�i � # LINES ��'� FIRST 2� INLET L /21 - OUTLET apt, 2" OR . 17 FT) TEE REQ'D? LEACHING ' 100' TO WETLANDS/!-""'""r 2% SLOPE RESERVE AREA �-~"` 4' FROM PRIMARY? (:�---'' 100' TO WELLS (... "", 351 TO FND & INTRCPTR DRAINS &,-," 4' TO S.H.GW 325' TO SURFACE H2O SUPP L..""~ , 4' PERM. SOIL BELOW FACILITY below MIN 12" COVER" FILL? '(25' if above natural elev,� 10'p ) BREAKOUT MET? ,.'.. TRENCHES , w" >3 ' COVER? - VENT // MIN 660 gpd_;�,r"f, SLOPE (min 005 or 611/100, ) SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) Irv " IS RESERVE BETWEEN TRENCHES? "- IN FILL? ,.1", MUST BE 10' MIN. "°,.... 4" PEA STONE'S 0 ." t,r X LDNG _c`��'° - TOT BOT X LDNG ft2) 5IDEDxL 2x#) (L x W x #) ( / ) DATE ✓�1 � Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE /o # t )c "�' DATE RECEIVED PERMIT 161519;4 APPLICANT ASSESSOR'S MAP dP ADDRESS PARCEL # LOT # IA" ENGINEER STREET ..A M d��fT l�'�d�� ,�° .� ADDRESS PLAN DATE ^� ' REVISION DATE CONDITIONS OF APPROVAL:,:7 ' ` APPROVED ' DISAPPROVED Ca " , "' .•�... ,�, ,. .-:.,,� , �..'... l n';w• ,�"r,1"�";;i,1 `�'fw'ly (�';+„4 ley',ti'c^�V �"I t 4T'`� \�! w�°jw1'! '"^�S'�day x� 3yR�'gv}'Rc r,r«"w 2"� RWM,4 °Y� a� �aa:�. a s 7 dr ti r, dJ ij .r, Town of North Andover, Massachusetts Form No.3 µORTH BOARD OF HEALTH ,b qti fi� �� o p 19 0•`�M DISPOSAL WORKS CONSTRUCTION PERMIT 1S^SACHUS�t Applicant__ NAME ° ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct (>�—or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH .- Fee ��� �� D.W.C. No. ��/ "ORTH at ,.• ..?aa _...: ., TH BOARD OF HEAL TEL. 682-6483 120 MAIN ET Ext. 32 ItS,,���. �� NORTH ANDOVER, MASS. 01845 �ACwu�k� JAN 2 5 1�`;aT January 22 , 1993 Les Godin Merrimack Engineering Services, Inc. 66 Park Street Andover; MA 01810 Dear Les: This is to confirm that at the Board of Health meeting held on January 21, 1993, the Board granted variances to North Andover regulations. 2 . 14-4 , minimum design flow for single family dwellings, for Lots 1 and 18 Old Cart Way; 17 . 03 , spacing between leach trenches for Lots 8, 10, 11, and 14 Old Cart Way; 4 . 18 distance to a catch basin for Lot 5 Old Cart Way; 4 . 14 to allow a twenty minute design rate. With these variances, all current lots on Old Cart Way have been approved, specifically, Lots 1, 2 , 4 , 5, 6, 7 , 8 , 9 , 10 , 11, 12 , 13 , 14 , 15, 16, 17, 18, 19 , 20 and 21. If you have any questions, please do not hesitate to call . Sincerely, v Sandy Starr FORKS U IA)T REIMUSE FORK INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone LOCATION: Assessor' s Map Number Parcel Subdivision JZva `1 i .a Lot (s) Street �� rc� kt, �i' St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved �� Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected i. .�;' 'C_ �__ Date Approved Septic Inspector-Health Date Rejected Commenta Public Works - se'„aer/water connections - driveway pe=- , it 7zk- Fire Department plodl,lcj +"a L✓ / ' Je c0n..f l Received by Building Inspector Date PETER F. REILLY AFFILIATED WITH F.P. REILLY AND SONS, INC, q i 205 ANDOVER STREET, SUITE 11 ANDOVER, MA 01810 (978) 475-4370 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: 240 Old Cart Way, North Andover, MA 01845 Address of Owner (if different): N/A Name of Inspector: Peter F. Reilly (I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name, Address, Phone #: Andover,llA 018100 978475-1237 Suite 11 475-4370 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information 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: Passes N/A Conditionally Passes N/A Needs Further Evaluation By the Local Approving Authority N/A Fails Inspector's Signature: Date: November 21, 1998 Pe er F. Reilly The system inspector shall submit a copy of this inspection report to the approving authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flaw of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the 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. INSPECTION SUMMARY: A. SYSTEM PASSES: Check A, B, C or D I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick ! Date of Inspection: 11/21/98 B. SYSTEM CONDITIONALLY PASSES: N/A One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined", explain why not) N The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. N Sewage backup or breakout or static high 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): N/A broken pipe(s) are replaced N/A obstruction is removed N/A distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): N/A broken pipe(s) are replaced NIA obstruction is removed 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 environment. 1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. 2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well. N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a private water supply well, unless a water 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 N/A (approximation not valid). f SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick Date of Inspection: 11/21/98 D. SYSTEM FAILS: N/A I have determined that the system violates one or more of the following failure criteria as defined 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. N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A Liquid depth in cesspool <6" below invert or available volume <'/2 day flow. N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: none N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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: The following criteria apply to a large system in addition to the criteria above. N/A The design flow of system is 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: N The system is within 400 feet of a surface drinking water supply N The system is within 200 feet of a tributary to a surface drinking water supply N The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the DEP for further information. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST i Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick Date of Inspection: 11/21/98 Check if the following have been done: / Pumping information was requested of the owner, occupant and Board of Health. I/ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note they are not available with N/A. V/ The facility or dwelling was inspected for signs of sewage backup. I/ The system does not receive non-sanitary or industrial waste flow. V/ The site was inspected for signs of breakout. / All system components, excluding the SAS, have been located on the site. / The septic tank manholes were uncovered, opened and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of SCUM. / The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. The size and location of the SAS on the site has been determined based on: ,/ Existing information (Example: Plan at BOH). DESIGN PLAN / "AS-BUILT" PLAN N/A Determined in the field if any of the failure criteria related to Part C is at issue, app roximation of distance is unacceptable [15.302(3)(b)]. PART C - SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow (gpd/bedroom for SAS): 495 gallons/day (165 gallons/bedroom) Number of bedrooms: 3 Current residents: 2 Garbage grinder: yes Laundry connected to system: yes Seasonaluse: no Water meter readings, if available: 279,000 gal. past two years / 392 gpd (includes irrigation) Sump Pump (yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of Establishment: N/A Design Flow: N/A Grease trap present: N/A Industrial waste holding tank N/A Non-sanitary waste discharged the Title 5 system N/A Water meter readings, if available: N/A Last date of occupancy: OTHER: Describe: N/A Last date of occupancy: N/A SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) i Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick Date of Inspection: 11/21/98 GENERAL INFORMATION PUMPING RECORDS and source of information: last pumping: 4/98 according to owner System pumped as part of inspection: no if yes, volume pumped: N/A gallons Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy NO Shared system (yes or no - if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: System installed as new construction in 12/94. Sewage odors detected when arriving at the site NO BUILDING SEWER: (locate on site plan) Depth below grade: 40" material of construction: cast iron 40 PVC ✓ other (explain) Distance from private water supply well or suction line N/A Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" material of construction: ✓ concrete metal FRP other (explain) Dimensions: rectangular - 1,500 gallons <1" sludge depth 32" distance from top of sludge to bottom of outlet tee or baffle <1"" scum thickness 7" distance from top of scum to top of outlet tee or baffle 15" distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) Tank was watertight and functioning properly. ii i r SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick Date of Inspection: 11/21/98 GREASE TRAP: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) N/A TIGHT OR HOLDING TANK: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Capacity: N/A gallons per day Design Flow: N/A gallons per day Alarm level: N/A Alarm in working order N/A Date of previous pumping: N/A Comments: (condition of inlet tee, condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) The d-box was level and distributing equally. No sign of solids carryover. PUMP CHAMBER: N/A (locate on site plan) N/A Pumps in working order (yes or no) N/A Alarms in working order (yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc.) N/A i SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick Date of Inspection: 11/21/98 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: not applicable Type N/A leaching pits and number leaching chambers and number N/A leaching galleries and number N/A leaching trenches, number, length three (3) trenches, 65' long each, per "as-built" plan leaching fields, number, dimensions N/A overflow cesspool, number N/A alternative system (name of technology) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance, repairs, etc.) Soils over leaching area were good, no evidence of breakout. CESSPOOLS: N/A (locate on site plan) number and configuration N/A depth-top of liquid to inlet invert N/A depth of solids layer N/A depth of scum layer N/A dimensions of cesspool N/A materials of construction N/A indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) materials of construction N/A dimensions N/A depth of solids N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick Date of Inspection: 11/21/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: indicate at least two permanent references, landmarks, or benchmarks locate where public water system enters house locate all wells within 100' N/A zo az l�\J 00946 yc�.o5 C� !�✓—iN__�cri? R z k _ ----Q oar'" ,� !+/✓ a__ Tom, 77I,;�vk rl .� � /N✓otiT � M m N� Ct.S� BAR �Qc SEPTIC TANK TIES: A to Inlet (1) 74'8" B to Inlet 38'8" A to Center (C) 80'2" B to Center 35'7" A to Outlet (0) 8416" B to Outlet 32'10" D-BOX TIES: A to Box 8716" C to Box 38'9" NOTE: The system is in the rear yard. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 240 Old Cart Way, North Andover, MA Owner's Name: John Broderick Date of Inspection: 11/21/98 DEPTH TO GROUNDWATER Depth to Groundwater >4' (below bottom of SAS) Indicate all methods used to determine High Groundwater Elevation: Y Obtained from Design Plans on record Y Observation of Site (abutting property, observation hole, basement sump, etc.) Y Determined from local conditions N Check with Local BOH N Check FEMA Maps N Check pumping records Y Check local excavators, installers N Use USGS Data Describe in words how High Groundwater Elevation was established: Design plan on file @ BOH indicated groundwater level significantly more than four feet below bottom of SAS. Grade sightings from the surrounding area confirm this. e 11 DISCLAIMER This passing septic inspection under Massachusetts Title V in no way guarantees the septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Peter F. Reilly Inspector November 21 , 1998 Commonwealth of Massachusetts �� City/Town of ° ° . r. Affift a System Pumping Record NORTH AND I VR Form 4 it�..l`/ b DEP has provided this form for use by local Boards of Health. Other i information must be substantially the same as that provided here. B ck ith your local Board of Health to determine the form they use.The System Pumping Record must be su mitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the s� computer,use only the tab key Address to move your �(;+c° ► cursor-do not — — -- — — -- ---_ -- State Zip Code use the return CitylTown key. 2. System Owner: .. vt Name Address(if different from location) 64y/Town State Zip Code .I o Telephone Number B. Pumping Record 1. Date of Pumping 3 0 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes [;]'No If yes, was it cleaned? ❑ Yes [�No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 I