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HomeMy WebLinkAboutMiscellaneous - 1465 Forest Street (2) 1465 FOREST STREET t 210/105.B-0007-0000.0 r 1465 FOREST STREET .0007-0 ' 210/105.6 • 000.0 f i f f s y MAP # LOT # PARCEL # STREET __.__. _._...._ -_. L.'.... CONSTRUCT LON__APPROVAL HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL: DATE ��/9� APP. BY._,---z � _.._ DESIGNER: V 7-;qz PLAN DATE:__��/ CONDITIONS WATER SUPPLY: TOWN WELL PERMIT DRILLER_ Q�>%NJQ� WELL TESTS: CHEMICAL DAIE APPROVED_.�Aiht. BACTERIA I DA I E (IPPRUVED 1./13/ - BACTERIA II DA 1'E APPROVED__._!.._..___..__ COMMENTS H FORM U APPROVAL: APPROVAL 1-U ISSUE YES NU DATE ISSUED 51g BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YE NO WELL CONSTRUCTION APPROVAL E5 NO SEPTIC SYSTEM CONSTRUCTION APPROVAL Y NO OTHER YES NO ANY VARIANCE NEEDED YES `NU 1By:FINAL BOARD OF HEALTH APPROVAL: DA1•E:,z . /7 ._.. ISTHE INSTALLER LICENSED? Y NO PE. OF NEW REPAIR :., .NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF..APPROVAL f YES NO a (FROM FORM U) ISSUANCE OF DWC PERMIT . YES NO = DWC PERMIT NO. 7A INSTALLER: M'/t'IcL�f !� BEGIN INSPECTION YE N0: -';,EXCAVATION .-INSPECTION: : NEEDED: • PASSED BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: = BY /J G FINAL . GRADING APPROVAL: • _ DATE � � � � BY .FINAL CONSTRUCTION APPROVAL: DATE: Id`�l �� BY Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1465 Forest Street Extension D 6ay- ��r cAvQ-"-'- -Loje�ej OL'o-f--S '� u V A �� Property Address Patrick Dello Russo A'��OW -tc�f3 Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every 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. Al In It Important: A. General Information When filling out forms on the RE EIVED computer,use 1. Inspector: only the tab key AUG 15 2016 to move your Dean Dynan cursor-do not t f I Name of use the return TOWN OF NORTH ANDOVER key. HEALTH DEPARTMENT Company Name �e 2 Suntaug Street Company Address Lynnfield Ma 01940 City/Town State Zip Code 508-726-9935 S112837 Telephone Number License Number I B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ( specf—or's ignature rate The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 '� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Cityrrown 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: 4 bedroom system in working order 1500 tank with two shallow pits tank pumped in April i B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Citylrown 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 Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Cityrrown 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? ® El information the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 GPD provided t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 4 bedroom single family dwelling 1500 gallon tank with two shallow pits Number of current residents: 2 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 well water 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No occupied Last date of occupancy: Date 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Homeowner/ Sytem pumped this year April Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed per plan on file 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Leet Comments (on condition of joints, venting, evidence of leakage, etc.): building sewer in good condition no evidence of leakage Septic Tank (locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon concrete septic tank 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 11'X 5'8"X 5'8" Sludge depth: 0-4" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 � Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is North Andover Ma 01845 7/28/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0"-3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? infield with measure stick and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank should be pumped every 2-3 years depending on number of occupants and usage Septic tank is in working order inlet and outlet PVC T with gas baffle Liquid is at bottom of pipe on outlet line with separation from inlet and outlet tank was pumped this year 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, level liquid q s as related to outlet invert, evidence of leakage, etc.): ) Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): i Depth of liquid level above outlet invert liquid is at bottom of outlet lines 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.): Concrete H2O 20"X 20"6 outlet D box with two oultet lines little evidence of solids carryover / no evidence of leakage D box 27" below grade/ D box located in driveway with risers and cover to grade for access i I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 pits 16'X 13' ❑ 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.): SAS in working condition/ no evidence of breakout / no ponding SAS located in driveway/green grass area with no damp soil and vegitation in good condition Pits are 28" from grade H2O loading Each pit has a vent 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 'i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ' � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Cityrrown 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 j Depth of solids i 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 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 7+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked date of design plan reviewed: 8/92 ' g Date ❑ 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: checked with health dept plans on file dated 8/92 No sump pump Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 +� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1465 Forest Street Extension Property Address Patrick Dello Russo Owner Owner's Name information is required for North Andover Ma 01845 7/28/2016 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 O { Y V• R r t � d "sits, 7ta asrfn> } \a `v s to IF 5a � 1 rx � r 7, �� •r..0 Z �� ate;. W. a S, ills 71 r, oai h :✓_./;a. rr .•�. :.,. fi=F' ma.k. ' ,''u✓ � �/ :'iii /a-. u/.:vf� ✓. ,J'"s . �. .. Y,.,. .� .,.., ?''�'�„�y, ,.! l! //, .,.,.. „�,,: r./ ._ ✓/ >� � r.. « arc r'xc ,� 7i.•�./ r �,''.s`:,, sw l ,s ..,ii;. , ,W �,9 5 4 n” 9. N, '"•T, WT .:�:�:-, ,., v:< '.r ...� ;'',. !' !�' Jr. a, n - .,r._ +.. 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Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. REC Important: A. General Information When filling out forms on the APR 2 2014 computer, use 1. Inspector: only the tab key to move your Jonathan Granz TOWN OF NUN IHANDOVER cursor-do not Name of Inspector HEALTH D-E-PARTB.4F—hIT use the return key. Preventative Septic and Drain L.L.C. Company Name 327 Asbury Street Company Address South Hamilton MA 01982 rerun Cityfrown State Zip Code 978-468-9001 S113405 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/14/14 In6owsitnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every 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: System is in good condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - - w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•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 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is North Andover MA 01845 4/2/14 required for every page. City/Town State Zip Code Date of Inspection j 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 ® El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, . dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 per plan t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information Description: System is composed of a 1500 gallon septic tank, distrbution box, and two leaching pits. Number of current residents: 3 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd))� n/a Detail: Private non-metered well. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: um Last pumped ed in 2011' per homeowner. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Truck sight glasses Reason for pumping: Inspection & maintenance 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: The as-built is dated 6/27/94 (see attached copy) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 17"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 85 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer is constructed of Schedule 40 PVC, it was found to be in good condition, no signs of backup, leakage or any other problems. Septic Tank(locate on site plan): Depth below grade: 7 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 4'D 5'Wx Dimensions: 101xj Sludge depth: 6" I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments ° G5 4 Forest St. Extension 1465 Stone Cleave Rd. 1 • Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure/SludgeJudge. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank is in good conditon, liquid level at outlet invert, no signs of leakage in or out, tank is structually sound. Inlet baffle is concrete and is in good condition, outlet has a PVC "T" in good condition. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 ;M 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0„ p De th of liquid level above outlet invert 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.): Due to the location of the distribution box being under the paved driveway, it was inspected using a camera from the outlet pipe of the tank, it was found to be in good condition, structually sound, water tight, no signs of solids carryover. There are two (2) outlets. Estimated depth to top of d-box is 30"+/-. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2@ 500 Gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system T pe/name of technology.- Y 9Y Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Ground over system is dry and consistant with the surounding yard, no signs of hydraulic failure, ponding, breakout, damp soil or abnormal vegetation growth. Due to the location of the leaching pits being under the paved driveway(Pit#1), and under the shed (Pit #2), they were both inspected using a camera from the vent pipes (each pit vented separately), both pits were found to have <1"of standing liquid. I Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 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.): Priv n y (loca a t on siteI 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 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 6'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7/31/93 Date ® 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: Soil testing was performed for the design of this system on 7/27/87 by J. J. Amato and witnessed by Mike Graf, during these tests water was found at 72" (see attached copies). The leaching pits were installed with a 4' seperation from groundwater(see attached copies), although there is no ESHGW determination for this property due to the age of the soil tests on record (pre-1995), there is no evidence that this system is interfacing with groundwater. NOTE-THE ONLY DEFINITIVE MEANS TO DETERMINE HIGH GROUND WATER IS TO PERFORM A SOIL TEST ON THE PROPERTY BY AN APPROVED SOIL EVALUATOR. IF A SOIL TEST IS PERFORMED ON THIS SITE IN THE FUTURE, THE RESULTS OF THE SOIL TEST COULD ALTER THE CONCLUSION OF THIS TITLE 5 REPORT. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1465 Forest St. Extension (1465 Stone Cleave Rd.) Property Address John Shinners Owner Owner's Name information is required for North Andover MA 01845 4/2/14 I every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater I ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I JoB halT'66ELY`w& 3LY0_ HANCOCK SURVEY ASSOCIATES, INC. 235 Newbury Street, Route 1 North SHEET NO. of DANVERS, MASSACHUSETTS 01923 CALCULATED BY -�L4's DATE Q (508) 777.3050 (617) 662.9659 (508) 352-7590 (508) 283-2200 CHECKED BY DATE SCALE IMOT ..... . ....:.... ......... ......... ...... ..... ...... ...... ...... ...... ...... _..... T t ... ..... ....... �. .............:.............,._........._..............:.. S1 ` .........................:.............................:............................:............................................................................................... ...... ...... ..... ...........:.......... ...... _ ..... ...... ...... .........._. . ... .... ......... ......... ..... ..... ..... ..... .. ......... ......... .. .........: .............a.... .... ..... ..................................: 4 13' P ...... ..... ..... ..... ...... .. _......... ...........................:.... ..................... .... . ....a.... .._:.... ....:.... ....:.... ....:.... ...... ...... ..... ....... ..... ...... ...... _........... ..................... ... .............. ..... ...... _.... �D .................._. ...... s.. ................................................_....................._............ ...... ...... .... ...... ...... ...... 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E 3 ..... ...... ..... ..... 4 3, .................. ..............:............ .....................:........ ._..... ..... ...... ..... . ...... .... _.. ..._ ..... ...... -.. ,..........._...._.__. .............. ...... - ..._ _............... ............................ ..... .... ...... ..... _ ... ..... ...... ...... ..... - .. ..... ..... ...... ...... ..... ....:.... ..-.... .._.... ........... ...:.. ...:............ ASCOEF PRODUCT DS625-1 I ANVALL Y, PUMP UU 1 ! 11 AS REQUIRED —0U7LET 6" DEP 77-1 OF 51,4"- t.. A _. . - 1 1/1?" STC,"VE ADQr x TANK W0 TH SSP IC _TANK rrmc& s C77ON NOT Tu,_ SCALF sEP nc TANK ) A RL E CAPACITY(GAL. T I~ A ..r B ' C T 1LGL R 1 5 1 t J �•, 4 2 1500 I10 0" 6'-0"5,-, 60 - -OUTLET (TYP.) 1'-0" MIP-'. :^o�ER SEE SPEC. B rr------ter ---- --- ',. INLET _ 2 OUTLET LOADING a —J L-- N-20 INLET DES/GN- p 1 6" NO. REO D BUILDING USE . NO. OF BEDROCK '.. �4�4PFL-E- (4c g) --J� -6" DEPTH OFS/GN FLOW. . I 3,.14'-1 1/2" -ARBA GE GRIND, PLAN SEC TI(-N STONE SPECIAL CONOLT, 6 - OWLET DIVRIBUnON BOX P.C T TC SCALE _9FS/GPd PERCOLf LEACH AREA RE FINISH SURFACE TOTAL AREA RE ------------ - _ r- FILL — °,.,$ Pt? WDED-Torg, A 111" O A� AND/OR t, 5 t MANHOLE , PAVEMENT cj Z__ STCNF_ SEE I I—� PLAN B SPEC, D ,EFFECTIVE WIDTH 'A' INLET z"DEPTH- SECTION 'B' >x- SI/8 TO 1/4" EE NOTE 7 STONE-SEE TABLE of DIMENSIONS D SPEC Wn v - 8 I------- . - " w EFFECTIVE LENGTH 'B' NO. RE0'D Ib�"D 13�'O, 2' I� LOCUS Mg -- SECTION 'A' TWO;:?;. SHALLQW____ A�FL PIT EA. PIT 500 GAL. NOT TO__�CALE L-CANA1ri ' t-'-?0 UNDERPQIV PER ' RA TE(tiUN/IN)i DA TES SOIL _ TEST_DATA Q. - W .1-N. 1.L 7 Nu. DA TE P:& ' TEST Br.-_J.�..AMAM, ._ ___ �P 4 MIN./JAI ,r z7 wITNEss:.MME OAAF,_HEALTH_AgNT L_ . . .. -_ i_. PROPC OBSERVA nON PIT T' (p T- / CEWA DA 7E -.4'A-_87. + 4-?4-e7- - ..-. 3 2.5 ROUND WA 7ER E-1. - Z�I•C?_ .._ .. ._—r_.. . ..L_? - s.. . S/TE PA BOTTOM EL...... 1I SEE ABOVE roP(svrjsaL — R�6NT roe AnDITIONAL. . .. o#i FO 'I"EST R�uLTS '` I^' ' TbP 4 5V86"L: Sf"„ NORTH toARSB Tt ^ 34':i►LTr = SA OY mcf-plu TILL t 6ACS;TO NFA�-- 130 W/MED�uM 5aNnn r X1. PREPARED R ����.oEQS .•�. w, HERI i r«NTt,Y ! Bo�k.DER� fu PAC!{FJ> f Z S 72 ----- _ - . _l. . G.��f•f, --j-- 2q SLI AXY VERTICAL SCALE- I- = (, GRADE OB->FI VE!' GROUNP WA TER V HS BOTTOM (NO REFJSAL) — "� — REFUSAL/LEDGE -- 727P 6C FL. 1451 nls�lZlf3crTic�i F3C)e —F_1(ISTII►1la CCNTGt,'R.5 14 G �-- i S459McAT Ft.cw'r2 BREA K C CT EL /37' L E . 135.(o IaS SPEC--,- PEC f i 4 DmPT cF TCP lt.. ti BC'TTC.M CG' PIT L • • E.L. 133.0 1c _ 4(M1W • -�-L GRoumn w4TFQ E_l.. IZ9.0 sI i L1.. I i FLOW P""*'Fl LE I a51 E-CAS7 RAFT:E :)R 'F TEE' f"F`: A r /7 YF ' i'J F7 A Ir. r1 t r - �:c.ar vm:,.,,....,,,,,rti F....>_:.��».�...,,-.. %EP n, ?r ?,4'" .t•_J l3 Y' y'e...dRM NIAf+lt'!s1 .. "% i£ �_���L �.���, �� a _- n�1?•�: x-19-�? 'A aNsTp _SEE SPEC. B DESIGN CRITERIA _ .. fyt 4 L I'�� f �1/ '.. ✓;E .$!N C .I.r. FA M t.!Y. /"ik/ 1 t .NE/,.e� . f f" ✓F1'k(.�'4S- FGt.r' .f!al .c.:ESrGf- %✓�. CF lF^f-f.L IF-H-- IT�P0 ?L-f Tyf!..r W. e-Z f7C,R . T('TAL C/1/(.Y F^ V .G:G: G . ; A L.L.G A1S `4" �.. >ARfjAvF GRIT✓/ER - ✓( X. vE�, ;i'Jr'frEASF_ L.FQC;N AkFA RY .50%) ;T'%!✓f SPE IAS ;>NOJTic;,/ . . . . . . Afc �cSl�1 PER CLAT FATE. FdVQ (Af � . all/ `4 H ARf a RE•117Rf_'aEf/T (sc.F T. ^.ALL(i'/j �( TTt.-'.� ;.. T AREA 4E� %-LuGAL Cc L- .573 S -T T/TL i. 4(c3 ".FT. `T_ ZC` f T.- lf'f:. ���" ;�%'F T. r �, ;;;;f � TiTAL 3?a,(�� -r�n'rT^tia. 8.'c� r,a SH OF lz -•wr.F QOM VACI AV V. �C JYALAIP ;' 34026 ON B [\ cmoli :TI .J NA o4 [i!MEI�S''JNS c� .�:�r�-i,r LOCUS MAP ALE .T-- TO c.R �. N1,Pa.'Ilo /t27 N. . JA TF RL1ISI J/✓ 6'Y Af'PR. PROPOSED SUBSURFA CE SEGE DISPOSASEWS YS TEM SI PROFILES & DETAILS T/E PLAN, LOT 3 FOREST STREET EXTENSION NORTH ANDOVER, MASSACHUSETTS_ PREPARED FOR: ,HETl VE BANK RI T4 GE COOPERA t/ASfIINGT0'✓ T, _"ALDI, ".lk-� CHUSFTT`' :CALF' Af '4`17,E,. , ESrGNET RY: -- /R ,. - ,ATF _ 1 q Y ,71, 199' _HF:XEf' RY. SAHANCOCK SURVEY ASSOCIA TTS, INC. -- -:. UNT .VA TER _�,5 ,,F VRUR Y STREET, �A^✓✓ERS, MA 0192 3 SHEET 1,::F T JOR `/x.3290-3 HSA HANCOCK SURVEY ASSOCIATES #3290-3 July 1, 1994 North Andover Board of Health Town Hall North Andover, MA 01845 Attn: Sandy -Starr, Health Agent 1 tem As-Built RE: Sewage Disposal Sys • g Posy Lot 3 - Forest St.' Extension, North Andover, NA Dear Sandy: I hereby, certify that the subject system was installed as shown on the enclosed as-built sketch. Please call ifY ou have any questions. V truly yours H 0 INC VACLAV TA #34 �c /STEL` �k4. ! W,/was FSS�ONAL b1Closures cc: John Shinmer • HSA File i I 3290Wr 235 Newbury Street•Route 1 North•Danvers,MA 01923•(508)777-3050•(508)352-7590•(508)283-2200•(617)662-9659•FAX(508)774-7816 HANCOCK SURVEY ASSOCIATES, INC. JOB 235 Newbury Street, Route 1 North SHEET NO., / OF Z DANVERS, MASSACHUSETTS 01923 Z 4- (508) 777-3050 (617) 662-9659 CALCULATED BY DATE (508) 352-7590 (508) 283-2200 CHECKED ,B(Y� DATE SCALE .............. ...... ... ...'........... '... .. ....i... .... ............_... ._. < ....i.... .......... __i..... .._.. ...... ...... ... ..... ..... ...... ...... .... ...... ..... ...... i t i f�] R ...........'..............! i 'S .............. ..D,SP. loT- ..-... .. r' ./ll._..f9.C./.: ?. /Elm....... . ...Irv/0.6.[v�Y L�O�C�SlT�..�. -e- ..V I.. _. UFA Sv_/z v_E�/ �9SSOG/ TSS, we. _ .ViSc ...... _... ..._<......._..............:.. . !7'. : ... .1� .:.. ' ,9AvLA�.i y' J/l1'C'0001� Sv, llC".Y.:.. 'SOC j _ lA/C, TM MEy/n/ /�.LCEie C3,e(. c . gv,� - 1Noar�C3v � . 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N� I i I I I ------------ C3 12) I I I I I i r � I w j I I r .x ' ,I F '• r +Jf i i �t5 1,'7 Ayr: 1'rV ;;f4 3" r'9° ►se 'r -'ri 4 r' y.. r� n: - _ i ' � P '6 r r �5' r \ \ r r 'L•y-r M S , 4 1 i�,.' �.L ♦ �' - �, t \"f • �� � .� t`'r, `"t -r�i r r.� e��S�� 1:��1 ti -, g� �i �,ej S� .a{ �'itn �a( ,A R ;� ��t:.3y: �, �. a. : t 0 J'. ♦� r�awr�14"_1 f r y r a a .'� tr i \\ .yr ,' r �.� �: ila J. '- i_ _ ._ - t.,4.. r ,v..c.,�r. �.a..�.,4n a..,n_<.aa-s�ai�n�i1�'tt LS'.'ti,"'`ta_.rt.,c. C��.rc .4. .��•re,,.. -.ae 4�... ...ins,..K�.`_... 7,.. I, y 5 'T,5VI(F WO c -- -- --- --r----- - Tr-5 ]rr, :Too i h.--r- "fib -- -- - - i-- Ll I I Diana Pinkham Realtor MA&NH REMAX Partners Zen 44 Park Street Andover MA 01810 978-475-2100 „ dlpre@dianapinkham.com dianapinkham.com 603-489-8671 Connect with me on facebook dianapinkhamrealtor dianapinkham _c�� = _ ol)-63_ d t � J. je7f7alA Ts �f cva d C2 1 � � I I �� W94J� •, jN o No................_....... �wn `.b. y d'U/► FEs.........................._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ OWN..._..............OF.....NQRTR.-ANDOVER. Applirtttilan for Uispnsttl Works Tianstrurtivit ramit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: LOT 3 -- FOREST STREET EXTENSION ................_................................................................................ ...._..•---•---••-----...._...._...•••........-�----------•----•---•---------------..........----•- HERITAGE COOPERAfiV i 71 WASHINGTON STRd� ,tIALEM, MASSACHUSETTS ......................_.......................................................................... Owner Address W Installer Address Type of Building Size Lot_--1.5. ACRES, *,� Dwelling—No. of Bedrooms.-FOUR (4)------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons__-_________-_______--_-__ Showers ( ) — Cafeteria ( ) a' Other fixtures ................................ . W Design Flow......165......................................gallons per person per day. Total daily flow..._.._._660----------- gallons. WSeptic Tank—Liquid capacity 1500..gallons Length! '_-0"_. Width6-'_-0".... Diameter-._._ __-.-- Depth 4'--Q.'-'-.. Z Disposal Trench—No. ........ ......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit NoTWO_S� )._.. Diameter.16'0"�X,r Depth below inlet_.2.•-1��-.__ Total leaching area.324.........sq. ft. Z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed byJ-.J_--.AMATQ,--.H_.S_A................................. Date..7427f.8-7_--.----••-•--••---- ,-a Test Pit No. 1.4.............minutes per inch Depth of Test Pit__120........... Depth to ground water...7.2"__......__.... (i, Test Pit No. 2.4.............minutes per inch Depth of Test Pit.. ZQ'..___._.. Depth to ground water...72'.'...........__. 04 .........................••--•........._................••••••••...••••....-•-•-•......------•--••••.........•.............................................. O Description of Soil........................:............... SEE ATTACHED PLAN) x W ••••....-•-•-------•...-----••-•-•---•-•--•••-•---••--••••-•--------•---•--•-------•--••••-•-----•------------------------•--•--••----------•--••••••---...•••-••--•-•--•••••......•-•-•-•----------••-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------------------------•-------•----------------•--..•........------.....--•--•-----------•-------•----------------•-------------------------------••-•-••-....--••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ----------------------------------------------------------------------------------------------------------- --------------------------------------- Dace ApplicationApproved By --------------------------------------------------------------------------------------------------------------------------------------------------- -----------------15;t.re......------...... Da Application Disapproved for the following reasons ........................ ................................................ . ............................. ........................................ Dace PermitNo. ..................................................... . .......... Issued ................................................................... Date —————————————.—_——————————— ——— ——————————————————————————————————————_———— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................................. OF -------------------------------------.-..............-----..-......------------------------------ Q-TWer#tfirate of C11jazttplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ------------------------------------------------------------------------------- - -------------- --------------------------------------------------------------------------------------------------------------------------------------------- Inualler at ............................................................................ ... ............ ......... ... .. ................................... ....................... .... ................................... ............. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..:........ .......................................... ... ................................ Inspector -----------------------------------------..-.-.................................................... -------------------------------------------------------- --------- -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F..............-----............................_...........---...........:........... No......................... FEE........................ Disposal Workii Tnnstrudilart "nutit Permissionis hereby granted..............................................--..........-----------------••----...---•--•-----..............-------•••-..............__.--- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ------•-•-----.....-•---•--•----•----------•-----•-••--....----•----•--------•----••••-•............... Board of Health DATE.................-•------------------------------------........................ Form 1255 H&W HOBBS&WARREN nn Publishers PITS MIN 660 LEACHING GW MIN 4' BELOW BOTTOM ✓ MANHOLE/PIT EXCAV 2x EFF W OR D7 A16 �- 12"-48" STONE SURROUNDING BOT ��� 3 + SIDE A3a x LOADTOTAL 8�9 (L x W x #) (2 x (L+W) x D x #) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE . 005 BED/TRENCH (Bed max. 60' X 601 ) BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W) x D x #) FIELDS MIN 900 ft2 LEACHING PERC RATE FASTER THAN 20M/IN GW MIN 41 BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE? 4" PEA STONE? DIST LINE SLOPE . 005? >3' COVER - VENT SCH 40 MIN 12" COVER L x W = T x LDNG > DESIGN FLOW? DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH PLAN REVIEW CHECKLIST ADDRESS .G QT�� / ���ST �T �,V'� ENGINEER �i9NCOG/� �U,e VGCy GENERAL / 3 COPIES (/ STAMP LOCUSy NORTH ARROW SCALE CONTOURS PROFILE SECTION BENCHMARK SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER t/ WELLS & WETLANDS WATERSHED? NO DRIVEWAY ✓ (Elev) WATER LINE v FDN DRAIN SCH40 1,-� TESTS CURRENT? SEPTIC TANK MIN 1500G. ,,/ . 17 INVERT DROP �� GARB. GRINDERA,/O (+200% EDF) r 25' TO CELLAR + 91,P9 MANHOLE TO GRADE --- ELEV 6AC GW OZ � D-BOX �`,Qy SIZE 8- 7 # LINES . FIRST 2' LEVEL STATEMENT li0 INLET/,3-f 3 7 - OUTLET 7 (2-- OR . 17 FT) TEE REQ'D? LEACHING RESERVE AREAL/ 4' FROM PRIMARY? t,," 100' TO WETLANDS I--� 2% SLOPE 100' TO WELLS 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GWL-"'- 325' TO SURFACE H2O SUPP / 4' PERM. SOIL BELOW FACILITY e/ MIN 12" COVER----'--' FILL? Z-- (25' if above natural elev;(10' f below) BREAKOUT MET?y Lowes P, r TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) >3 ' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? BOT X LDNG + SIDE X LDNG = TOT (L x W x #) (G/ft2) (DxLx2x#) t►ORTI� BOARD OF HEALTH F _ p Ic • 120 MAIN STREET TEL. 682-6483 �SSACMUSEt NORTH ANDOVER, MASS. 01845 Ext23 October 27 , 1993 Hancock Survey 235 Newbury Street Danvers, MA 01923 Re:- -. Lot #3. Forest Street To Whom it May Concern: This is to notify you that your septic plans for Lot #3 Forest Street, North Andover have been rejected for the following reasons: 1) Show location of foundation drain and outfall with O/C elevation. 2) Please specify metal access cover over D-Box. 016 3) Breakout for lower pit. 0� 4) Specify amount of stone around pits. 4A'f' 5) Would like to see D-Box not under driveway-o t"- A re-submittal fee of $25 . 00 is required for each request for review of revised plans. If you have any questions concerning this letter or the North Andover Regulations, please do not hesitate to call me at the Board of Health Office. Sincerely, Sandra Starr Health Agent SS/cjp c: George Belleau ew W/ 1,r'0uND471_oA.J �HQN CALL 7 0 2 FOR DATE V TIMEA.M. 01, OF Lln,4l Pt tQfVED (1^ PHONE ­7Al TURNED �j y! �Yi�URCALL AREA CODE MB A E ENSIO ` MESSAGE ��. 'LEAS7 CALL WtL CALL At',A1N CAME-To,. . Ybu. _ d NT5 TO �® Y — EE ,,�M. YOU SIGNED _T M 4003 NOTES i I Town of North Andover, Massachusetts Form No.3 LoRT#4 BOARD OF HEALTH 2 L DISPOSAL WORKS CONSTRUCTION PERMIT SSACHUSE Applicant X. CV-N VJ-JJ lAV NAME ADDRESS TELEPHONE i Site Location a; Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. r• h• �I f; CHAIRMAN,BOARD OF HEALTH „••jam r () V i Fee I D.W.C. No. a— C i /address_l46,5 �=02 psi _ Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes. action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department Town of North Andover, Massachusetts Form No.2 MOR?" BOARD OF HEALTH o 0� 19-13 P « s DESIGN APPROVAL FOR r C" SOIL SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. Site Location 1�-t3 d � Al— � - t,- Reference Plans and Specs. ENGINEER DESIGN DATE a- Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. •t; CHAIRMAN,BOARD OF HEALTH }. 7 Fee Site System Permit No. to L y" a FORM U - LOT RELEASE FORM 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 licable local or state law, regulations or requirements. *************.***Applicant fills out this section***************** APPLICANT; John & Kathy Shinners Phone 617-387- 1645 LOCATION: Assessor's Map Number 105B Parcel 0007 Subdivision Forest Street Lot(s) 3 Street Forest Street St. Number � � �� ************************Official Use Only************************ REC O NDATIONS OF TOWN AGENTS: " , oZt CWF Date Approved 2 Conservation Administrator Date Rejected Comments V,R) t.hit&a Date Approved J� Z Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected J7 - A , Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections ✓/�l /i (. - driveway pe it / 5, �/�/^� Fire De P artment \ T Received by Building Inspector Date i HSA HANCOCK SURVEY ASSOCIATES #3290-3 r July 1, 1994 North Andover Board of Health Town Hall North Andover, MA 01845 Attn: Sandy.Starr, Health Agent RE: Sewage Disposal System As-Built Lot 3 - Forest St. lctension, North Andover, MA Dear Sandy: I hereby certify that the subject system was installed as shown on the enclosed as-built sketch. Please call if you have any questions. V truly yot H D INC. VACLAV TAL #34 V c ale' �c /ST5-: W,/was NAL ENS\ Enclosures cc: John Shinmer • HSA File 3290VVT 235 Newbury Street•Route 1 North•Danvers,MA 01923•(508)777-3050•(508)352-7590•(508)283-2200•(617)662-9659•FAX(508)774-7816 1� », IOB h+-_e-Z1 d&_ GAO-U13 111le 13 �Ty-3 HANCOCK SURVEY ASSOCIATES, INC. 235 Newbury Street, Route 1 North SHEET NO., / OF Z DANVERS, MASSACHUSETTS 01923 CALCULATED BY �8S DATE 69 (508) 777-3050 (617) 662.9659 (508) 352-7590 (508) 283-2200 CHECKED BY- Q CDATE SCALE��L�� �/ .......................... .._ S�7-cl�Ca " L'JlSP05�/ 1�c>l L7" .. ............ YS7�M '�- . . . ..... .. . Z0.77-3. 2 .... Aidk '.GE cc p .. .........Y.. f /CQ� Sv/�VE`/ �'SSDC. T�.S, lrCVLSC� // f. ..9<3. � � . ........... VC TiM . MEI/�N ../it/STiq Lf? .13x W4 B � �5J..... 8Zy - NG 70/t /. . ..........-.......... ........... ........... LEU,4T1O�/S ..... ............ 14 r5 eLaY 9770AI f� IP7 0AJ ...... _ _ 3,34 14©.SZ �� , 137 $ 17.8 (� O tc" ... .:. ..... .. ... . .... 2 `�Z 137,tio' _ I ) Novs ` oc�T- ..... 3. (7 ._ (�19Z._ ...�f3� 5_ ,.. 5T /llL _..._. . ........... ..................:.... ..... . _r DvT T ........... 141.81 137agg- `CBM . (," QA . _ .N-AlL ' .... J ... o........• ...... 1' 11 J .. .... .: ..... .4- -.... ._.. ... - ..... ... .. .... ..... :..... 5,99 l35Z* / 44 _1*3OX . . 3o)13s8l.Jh7- - U - PP ( `ET Loc� c, z_12 X ......... . : . .. .... Z£3.. ►� s3._. 1 .1s" FI-�' ... 1.NL 1: -_ ^ _Pf2 .. .°. .......:....................................:. 1..11L.E-1'^..... C3 SL M f RODUCT DS625-1 A B C D E f HANCOCK SURVEY ASSOCIATES, INC. 235 Newbury Street, Route 1 North SHEET NO. OF DANVERS, MASSACHUSETTS 01923 CALCULATED BY- DATE (508) 777-3050 (617) 662-9659 (508) 352-7590 (508) 283-2200 CHECKED BBY/ DATE SCALE /VDT ✓ // 66-494 ..............:..............:......—............:...................... ..... ..... ..... .... ...... ........ ..... :..... i ....._.....'..........................i..............i........................._i..... ..._..__ ..... ..... .... ...... ..........................i........................... .i...:..._................ _.._—t............. ..... ....... ...... ........... ...... ...... ...... ...... ...... ...... ............. ...... .. .... /� i - .......................................'............. .... ..... ...... .... 4 �...... ...r.... ..... ..... ...... ...... ...... 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PRODUCT DS625-1 A B C D E F 4 DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER / SUBSURFACE DISPOSAL DESIGN REVIEW FEE_ PERMIT # &11,3 DATE RECEIVEDe/7A.3 APPLICANT _�C��C'G� --Z6LLEA ASSESSOR'S MAP ADDRESS PARCEL # LOT # 3 // ENGINEER fl/�xV ,nek su zf: STREET ADDRESS co73.3 /V&&)AU.eV 5/-, PLAN DATE 7 3//1,3 REVISION DATE CONDITIONS OF APPROVAL: APPROVED //y/vr 7 3 DISAPPROVED x Bk&&q -='o 07- ;=io'e �auJ�� Ali JOB - HANCOCK SURVEY ASSOCIATES, INC. 235 NewburyStreet, Route 1 North SHEET NO �^ of /- DANVERS-; ASSACHUSETTS 01923 CALCULATED BY `�,' > DATE— (508) 777-3050 (617) 662-9659 (508) 352-7590 (508) 283-2200 CHECKED BY DATE SCALE J— i 4 13' 40 1 Zl,3 S% A f3C TES Z 3 5, _3 IqLL Z9 i 3� d 3 ............ PRODUCT OS625-1 A 8 C 0 E E JOB_- HANCOCK SURVEY ASSOCIATES, INC. SHEET NO. ` OF L' 235 Newbury Street, Route 1 North DANVERS, MASSACHUSETTS 01923 CALCULATED BY DATE �> l ' (508) 777-3050 (617) 662-9659 (508) 352-7590 (508) 283-2200 CHECKED BY }�J DATE SCALE / :�.✓Li tom, L.' iv; JF '..L:_ .!y✓ _SIT79 Ti�/ V�A/- Ir�/GQ,Bv�;Y CO ,CST/�UGT1 ,11 -SSUM .......... Sv/z'V6 _ . /_T " ��� �Scr�ti/Li9/� / - Ho4/�lCOC1� 5 /C"Y_ S'SOC, � llt' Tim . MEL v/4 I, �3czc �!c' Dc>f2Y 1NoaD3v�� ��` 'G776 LEV.4T10&15 t7oN tsC�i�'7TlO.v 1,3 34 Ido,$Z 1n, 1 g 't si`j Oic� I4 [\j A.) 4_1 _ 232 137,90 (13�,sZ) I�OUS� Ov7 ..... ............. 4.1 T 13 ,Zs) _slT OUTLET . _ !_ 4;,33 14i8113?.4g -Tari ..... 5,9cl 8 ` �/ 544)' _85OX JMLE7` 13 135. 8 x/35,30) j 130 :_ cT .I (uPPE I4 (3s .(D7'l (l3s,Zq) TDBOY Out eT ° l2 � --, .. .: . z8 13sS3 PIT /3Z•�8 '1 __1_J�-LLE�^ E.r_--va-rj 0�'j I d.� , 48 To P OF,, .FoOMPADO�j 39: 0 � 13As(-:� ME NIT PRODUCT OS625-1 A B C U E f aG�� HANCOCK. SURVEY ASSOCIATES #3290-3 July 1, 1994 North Andover Board of Health 'Down Hall North Andover MA 01845 Attn: Sandy Starr, Health Agent RE: Sewage Disposal System As-Built Lot 3 - Forest St. Extension, North Andover, MA Dear Sandy: I hereby certify that the subject system was installed as shown on the enclosed as-hilt sketch. Please call if you have any questions. V truly yours H 0 INC. V ACLAV V. TAL #340 �cF /S V& VVT SS/ONAL ! Enclosures cc: John Shi7tmter HSA File 3290Wr i 235 Newbury Street•Route 1 North•Danvers,MA 01923•(508)777-3050•(508)352-7590•(508)283-2200•(617)662-9659•FAX(508)774-7816 o oN'6ftAndover iY - ' North, Andover, Mass., J* 19P y i BOARD OF HEALTH PERMIT To BUILD Food/Kitchen Septic Systemz� BUILDING INSPECTOR THIS CERTIFIES THAT........fr*. .. .".t 4r1xewo.04 �.......4!T Foundation .1',eQ�a 2— has permission to erect.41MAK00M..Af I I d I n g s on ON40.S.00.41...... ............X.. ... Rough o < t0 be occupied aS.. ., himney pe(:29 provided that the person accepting this permit shall in every respect conform to the terms of t e application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspecti r4F2un%1FNft=dIftof 1 Buildings in the Town of North Andover. REGULATED BY PARA. 114.8-S. B.C. PLUVBIN INS ECT R I VIOLATION of the Zoning or Building Regulations Voids this Permit. ou � ` Y DATE FEE DA1!D;/aD O Q Final PERMI`r r,XPIRES IN 6 MON'1 1-IS �,�� �:�' �� LECTRICAL INPE ,� PERMIT FOR FRAME/BUILOINCSS CONS�I C�'1_ CTION STARTS ,d � � 0 Rough 9l DATE J -? FEE PAIDy1r.... /= ...... .. .. ..... ....... ... ..... Service Jas BUILDING INSPECTOR Final occu p(oi 'rye [-'er Yl.i t R6,, a i"r ei.:l to OC(a tpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough p y p Final ' No Lathing or Dry Wall To Be.Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT i Burner ko�(A 1 Lk e�iy y Street No. 1 PLANNING FINAL CONSERVATION � 1 ENTRY PERM Smoke Det. .� SEWER/WATE INAL DRIVEWAY i Biomarine 16 EAST MAIN STREET, P.O. BOX 1153,GLOUCESTER, MASS.01931.1153 TELEPHONE: (508)281.0222 FAX: (508)283-3374 CERTIFICATE OF ANAL PSIS MR JOHN SKINNERS REPORT NO.: 940801 LOT 3—FOREST ST EXT MAY 18, 1994 N ANDOVER MA 01845 i fie: RNRLYSIS OF WELL WRTER i Well Descri tion: New well, 230 feet deep, located at the above address. m lin : Samples taken by Don Robinson on May 11, 1994. Fin in Parameter Results Guideline' Total Coliform Bacterial Count/100 mL(MF) . . . 0 0 pH Value 6.55 Slightly Acidic Hardness(CaCO3, mg/L) . . . . . . . . . . . 25.6 Soft Nitrate Nitrogen Content(mg/L) . . . . . . . . 0.12 10 Specific Conductance(Nmhos/cm) . . . . . . . 72 mapper Content (mg/L) . . . . . . . 0.0 Iron Content(m 1 1,3 g/L) X0`1 1.3 Manganese Content (mg/L) =0:1-6- 0.05 Sodium Content(mg/L) . . . . . . . . . . . 6.4 28 M to h s: Analyses performed in accordance with Standard Methods for the Examination of Water & Wastewater, 17th Edition, 1989. TGuldelines are based on the recommended levels of the Mass Department of Environmental A,Protection Agency's 310 CMR 22.00, "Drinking Water Regulations"and the"Safe Drinking Water ct"of the United States Environmental Protection.Agency. i Remarks: The Iron and Manganese levels detected may cause the water to taste"rusty"and stain clothing and plumbing fixtures.,;Fftration'is;available to correct these levels if continued sage and flushing of the well does not cause them to abate. ' i By. John Marietta Lab Director JM/dn i i " a . NUMBER FEE 402 THE COMMONWEALTH OF MASSACHUSETTS $25. 00 TZWN---------- of ---------XORTH--- MIaaVF.R-------------- ------ This is to Certify that .----Robinson Artesion Well Co. . . . . . . ...............................•--------......--•--...........---- NAME 160-_Forest___Hill Ave.__,___Lynnfield, MA 01940 ADDRESS IS HEREBY GRANTED A LICENSE For ..................Drilling---Well---a.t-.Lat...#-3... ares.t---street j.40.................... This license is granted in conformity with the Statutes and ordinances relating thereto, and expires---December ---1-- 1994_ finless soon d or revoked. . - ;..-------- Ari1 13 = 19.94 ` --- ------ ---- -------: ............ ---------------- ----- - -- ----------- ------------------- ---- .............. FORM 433 HOBBS 8 WARREN. INC. Q�/ jz rte., to '1N 'q.�.°' �,^," ;at y3�+x.a�,�tt�y�r�' }r ii���Y6�tiy�"�w�7� 1t �45.`y°'L,^'�its )n\a`'•,.i S��Y,., r�.�;. r r i, � 1i t `, A`t.�`��Z ��)l �ra�4 jY�.t � ,7.ti A�4 �L �,! ` h�\�}1�,� ai�♦._ , t NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS $25. 00 ......TOWN... of .....NQB.TJJ._.1 N.QRTJJ.-AND-Q_VEp. ............. This is to Certify that . EM -•Young ------------- NAME 36 Pelham Road Salem N.H. 03079 ADDRESS IS HEREBY GRANTED A LICENSE C� For ._...._.__WellDrilling Permit___- Lot__. 3__Forest Street_ •---••----------•---•-----•----------------•----...-••-----------------------------•-----••-----•----•-•--_..: -----•••---•----•----•---•--•••-•------•---••---•---••----•---•-------••----•-•-----•--...•-----••---•-•--------------•--- -------------------------------------•-----------------------------------•-------....---.....------------------•-•---........................................... This license is granted in conformity with the Statutes and ordinances relating thereto, and expires.--.�eCem} _r-....31•.-•••19-9-4•-------•--•---unless sooner sus d d or rev ked. ' F.!- . Y mune ..................................19-9.4. i. ------ ------ -- --•-----•-------- --- -• -•-•••-----•--------•-------•--- FORM 433 HOBBS 8 WARREN, INC. �+, r .� WELL DATABASE ADDRESS: AGE OF WELL: WELL DRILLER: WELL PERMIT.-r': Lto WELL LOCATION: .--W=PERMIT DATE: —1 — DEPTH OF WELL: � TYPE OF WELL: DRILLED b. DUG c. UNKNOWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OT=R CONTAMINANTS: Y i WELL DATABASE ADDRESS: 6 `"Z' C5 �GR AGE OF WELL: WELL DRILLER. WELL PERMIT�: WELL LOCATION: WELL PERtiIIT DATE: DEPTH OF WELL: TYPE OF WELL: a.. DRILLED b. DUG c. UNKNOWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE:. HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N