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HomeMy WebLinkAboutMiscellaneous - 136 CARLTON LANE 9/24/2015 (2) • �'T LPvJJ,� • j hml/L' ml%' iPo `A PUBLIC HEALTH DEPARTMENT T Town of Forth Andover Community Development Division CERTIFICATE OF COMPLIANCE As ®f: 9/22/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair Complete By. John Soucy At: 136 Carlton Lane Map 106.0 Lot 0098 f t Andover, Ih Issuance of this eel tifica e shall not be construed as a guarantee that the system will function satisfactorily. w Michele Grant �ublic Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com I t1 1 it°,;,,0%%/❑/%0 North Andover Health Department tommanity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 136 Carlton Lane MAP: 106.0 LOT: 0098 INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 9/22/15 D-Box 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 ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ 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 ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: i Commonwealth of Massachusetts Map-Block-Lot 106.00098 BOARD OF HEALTH ------------------------ ------- Permit No North Andover BHP-2015-0384 FEE $125.00 ------------------ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John-SouCY to(Construct)an Individual Sewage Disposal System. at No 13 6 CARLTON LANE as shown on the application for Disposal Works Construction Permit No. BHP- f5,-p38° Dated September 16,2015 r BOARD ObH 1 a BO' - -- --- Issued On: Sep-16-2015 F HEALTH Application for Septic Disp9sal System 9/15/15 TODAY'S DATE Construction Permit - TOWN OF $ 250.00-Fu ll Repair, NORTH ANDOVER MA 01845 $125.00 - Component t 1 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? "D" BOX '°" ' ✓ to move your cursor-do not use the return A. Facility Information key. 136 CARLTON LANE Address or Lot# � N. ANDOVER ��� �� City/Town ��� " ��A 2.-*TYPE OF SEPTIC SYSTEM*: S F P 1 ➢ ❑ Pump ❑ Gravity(choose one) ***If pump system, attach copy of electrical permit to application*** 'rovw4 0F NOPUll l4OXk(Y,4U,1 ➢ ❑ Conventional System (pipe and stone system) HEALTH DEPAlRTI iqf ➢ ❑ 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) A ❑ 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) Wlhat is the Make? What is the Model. 2. Owner Information RICK PIECEWICZ Name Address(if different from above) City/Town State Zip Code R.PIECEWICZ @COMCAST.NET 978-314-1200 Email address Telephone Number 3. Installer Information JOHN SOUCY SOUCY SEWER SERVICE INC Name Name of Company 78 N. BROADWAY Address SALEM NH 03079 City/Town State Zip Code 603-216-7175 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 Application f r tic Disposal t . Construction Permit - TOWN OF TODAY'S DAT NORTH V 0184 $125.00 -Component// PAGE 2 OF 2 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 sewag . posal system in accordance with the provisions of Title 5 of the Environme al C de, as well as the Local Subsurface Disposal Regulations for the Town of North A over. understand that until a final Certificate of Compliance has been issued by this and of H a/th, the instal system is not approved. f, a Date ;plicaf ion Approve ¢y (board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: Z Fee Attached, Yell- No 2. Project Manager Obligation Form Attached' Yes No 3. Pump S sy tem? If so,Attach cove ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvalletter, all papernTork received. Yes No Missing: 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 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Ad�esaoFarp6cayo�u� p«zP�u,67 141114- application Relative to the And dated I)^te6 A (")/ oDdbov�iouodated " 01,am revised dare) I understand the following obligations for management of this project: \. As the installer,I ucoobligated to obtain all permits and Board o[Health approved plans pdot to site.performing any work on u x . being done. 2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager,ozany other person not associated with my company schedules an inspection and the system is not ready,then item three shall 6capplicable. 3. /\o the installer,Iuou required tohuvot600cc000uzynmzkcooplctzdDz6ztnc6cupplicu6lciuopccdonoxo indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health RegWations maj result in a$50.00 fine being levied against me and/o m��company. � o. Bottom of Bed—GeoozxDv this is the 8znt /1"� inspection oolean there is u retaining wall,which � should be done first. The installer oouotrcgueat the inspection but does not have no be present. � 6. Final Construction Inspection—Engineer roum8rxt6oL6eir6zopccdoo6or elevations, ties, etc. As-built of verbal{}K(or e-mail to: from the engineer ozoat 6c submitted to the Board of Health,after which installer calls for uo inspection time. Installer must be present for this inspection. With xponzp uyntcoz'all electrical work must be ready and able to � cause pump to work and alarm tofunction. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to6000-oitc. 4. As the installer, I understand that only I may perform the work (other thall sim plexmcamntiox)and Iumrequired 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. Au the installer,I understand that I must bzon-site during the performance of the following construction steps: u. Determination that /6x pmnherx/v*abom of the excavation has been mxwxhxul b. Inspection of the sand and stone to be used. c. Final inspection b~ Board »fHealth staff or x*n/u/txwt. d. Iwsta--'''w of tank, D-Bo'` pipes, stone, vent,pump x&umbxr, retaining wall and other |� | components. approved plans. No instructions by the homeowner, general contractor. or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (T( day's Date.) f-74-7-11 ( Z_ (Narne Print) e—?rcl) _ As the installer,I understand that I am solely responsible for the installation of the system as per the i i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION j i TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 136 Carlton Ln. No. A n over, MA 01810 Owner's Name: Michael Werner Owner's Address: Same as above Date of Inspection: 08702701 Name of Inspector: (please print) John J. Soucy Company Name: Soucv I s Sewer Service Mailing Address: 830 L _va ngst-nnn t � wksbi= ma (')1 R76 Telephone Number: ` A 7 R,�, a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title S(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: At Date: The system inspector shall sub it copy f is inspection 4ort to the Approving Authority(Board of Health or DEP)within 30 days of complet this ins ection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and a system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address hpw the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 136 Carlton Ln. No. Andover, MA 01810 Owner: Michael Werner Date of Inspection: 08/02/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 136 Carlton Ln. No. Andover, MA Owner: Michael Werner Date of Inspection: 08/02/01 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 6 Carlton Ln. NO.Andover, MA 01810— Owner: Michael Werner Date of Inspection: 08/02/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _Z_ 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 -x— Liquid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] no (Yes/No)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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• 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) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 3 6 Carlton Ln. No. Andover, MA 01810 Owner: MichaeI Werner Date of Inspection: 0 8/0 2/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health x 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) x Was the facility or dwelling inspected for signs of sewage back up? --jL Was the site inspected for signs of break out? — x Were all system components,excluding the SAS, located on site? _ -.2L Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of scum? _ x Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no z _ 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)[3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: .136 Carlton Ln. No.Andover, MA 01810 Owner:._Michael Werner Date of Inspection: 08/02/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4 4 0 Number of current residents: 1 Does residence have a garbage grinder(yes or no):ye s Is laundry on a separate sewage system(yes or no):U_Q [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)):See attached Sump pump(yes or no): NO Last date of occupancy: X01 COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: PUmped in 19 9 6 Was system pumped as part of the inspection(yes or no):ye s If yes,volume pumped: 1 500;allons--How was quantity pumped determined?gadge on truck Reason for pumping: MAi ntenance and inspect interior of tank TYPE OF SYSTEM XX Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components date installed(if known)and source of information: iq.8 1 Were sewage odors detected when arriving at the site(yes or no):NO 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 13 6 Carl ton Ln. No. Andover, MA 01810 Owner: Michael Werner Date of Inspection: 08/02/01 BUILDING SEWER(locate on site plan) Depth below grade: 1611 Materials of construction:x cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 3" Material of construction: x concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 6 'x 1 1 ' Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: 3 8" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 16 How were dimensions determined:Tape and s 1 udge tool_ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pump Annually GREASE TRAP:a4Alocate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 CarltonLn_ 01810 o, n over Owner: Michael Werner Date of Inspection: 0 8 0 2 01 TIGHT or HOLDING TANKN/(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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: x (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Flow checked O.K. PUMP CHAMBER: N/A(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of l 1 . OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 3 6 Carlton Ln. � No.An over, 1810 Owner: Michael Werner Date of Inspection: 0 8 0 2T01 SOIL ABSORPTION SYSTEM(SAS): xx (locate on site plan,excavation not required) If SAS not located explain why: Type x leaching pits,number: 2 ( shallow) leaching chambers,number: leaching galleries,number: 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 si ns of hydrolic failure, or vegetation CESSPOOLS:N,LA.(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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 Carlton Ln. No.Andover, MA 01810 Owner: Michael Werner Date of Inspection: o R lo2j 01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. 4 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:136 Carlton Ln. No. Andover, MA 01810 Owner:Michael Werner Date of Inspection: 0 8/0 2/01 SITE EXAM Slope Surface water xxCheck cellar Shallow wells Estimated depth to ground water 6+ feet At elevation of existing pits Please indicate(check)all methods used to determine the high ground water elevation: x Obtained from system design plans on record-If checked,date of design plan reviewed: x Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used augger in low area across driveway, encountered ground water at 36" down Ground elevation diff rance 4 ' 11 f II oti r LA N N 40 N ® 6A ® Lt1NN © m 4.1 CM LA 0 M 0t'904 •Aai mt^ •o xWt T �r F- N LM M N Gq f {{ r J OaD W 'V`1 © 000OOQDtIDOQO sl��'S 16 ca QQQ © QGI © QTTfr Y' da do•• 0 © tDmtl7tDmC90000 5 �y fsif tl 3 19; Q4J1;i A © 11; ® G+ b © m f 1 A is Iti ® 9D M m ob 00 LA N 1% h0 1 W . • I n• L4 di 8O LAI• N1 N• ®� h� a�N� .7� al" a -? 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Board (-f' Health .-1artY, `ado ga, s SUBSURFACE DISPOSAL DESIGN CHECK I isT , L OT APPROVED IDISAPPROVED DATE Provided: asons: Title 9 FAIL OK Reg 2.5 The submitted plan must show as a minimum: mum: the lot to be se ed-area, ensions lot #,abutters location and log deep observation hoes-distance to ties c location d results percolation tests-distance to ties d design calculations & calculations showing required leaching area ` f (e) location and dimensions of system-including veserve area f) existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or - ' disclaimer-check wetlands mapping (h) surface and subsurface drains within 100+ of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of s ge disposal --- system or disclaimer-Planning Board files (3) knom sources of water supply within 2001 of sewage disposal 8 system or disclainer k) location of arT, proposed well to serve lot-loot from leaching facilit, 1) location of water lines on property-10' from leaching facility location of benchmark (n) driveways l (o) garbage disposals t- Irp) no PVC to be used in construction �q} profile of system-elevations of basement' plumb., pipe, septic tank distribution box inlets and outlets, distribution--field piping and Other elevations Cr) maxLmum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law, to prepare such plans Reg 6 Septic Tanks r (a) capacities-�50% of flow, water table., --tees., depth of tees, access, punping 6-" (b) c1 out (c) 10' from cellar tell or inground avimzdmg pool P (d) �5, from subsurface drains Reg 10.2 Distribution Boxes {a} -8-10—Pe greaten° than 0.08 Reg 10.1 , SBo of Health SEPTIC over INST,LAT IC LOTNorth Ano ° pI PR X AVATI J OK exanst �ye 1 FAIL ,$ 1. Distance To! a. Wetlands b. Drains c.. wen 2. Water Line 'Location 3. No PVC Pipe 4. Septic Tank a. _Tess -_Length & To Clean Out Cowers b. Cement Pipe to Tank •- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow Leach Field or Trench a. Dimensions b. Stone Depth c: Capped Ends , - d. Clean Double'Washed Stone` 7. Leach Pits ' a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cment Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9, Final Grading Inspection 10. Barricading Covered System a 11. As Built Submitted !t 6 a. Lot Location b. Dimensions of System c. Location with Regard-to Pore Test d. Y l erv-ations ` ; e. Water Table Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 Record must DEP has provided this form for use by local Boards of Health. The Sysltem.Pump:Ing be submitted to the local Board of Health or other approvi ::t ED A. Facility Information |mpwdam* `3 E I 2007t When filling out 1. System Location: forms onthe 1EAL1 I DO AR computer,use only the tab key Address w move your vvnm,-donm ��� Zip | uoomvmmm ~v''~`~' � key. 2. SyAM ow numo (\ Address(if different from location) Qty/Town u q_7Kqjfi - - 14 Telbphone Number B. Pumping Record | / / 1. Date ofPumping oum 2. Quantity : 1 Type ofsystem: E-1 Cesspool(s) ]�l SepticTank Fl Tight Tank Fl Other(describe): 4. Effluent Tee Filter present? Fl YesXNO (f Yes,was itcleaned? E] Toa Fl No 5. Condition ofSystem: S. Syat P d Q Name 7 VV Vehicle License Number 7. Location where contents were disposed: � � hUp://www.maaa.Qov/deo/wnter/opprovo)a/t5fznns.htnn¥inoped t5nnnn4.doo~0603 System Pumping Record~Page 1vr1 lisetU ' f iy aLotPW-tjMr'P-ft1 fJ-R9-cQ-"' Sysleoll Osvile" system Vocaiiol► ()tlailtity PtImped: gallons Cesspool: No yes Sej)jie ,j,ajjk. No Sysleill 111111►ped by: I-Acellse #J_-__-------- collic,I)IS lo : DOW Inspector: