HomeMy WebLinkAboutTitle V Inspection Report - 31 GRAY STREET 1/26/2006 ' COMMONWEALTH OF MASSACHUSETTS
S 1
ExECUT OFFICE OF ENVIRONMENTAL AFFAIR � � r
a° n
NT OF ENVIRONMENTAL PROTECTION EPAR TMT
R �
JAN 3
IVW i
�(O
TITLE L I ��� n
n
OFFICIAL,INSPECTION FO1tM,:,,.NOTFOR VOLUNTARY ASSESSMENT
UB U FACE SEWAGE UI Ip01
,.PAI'T T A �
"
� �
CERTIFICATION
Property Address: br 4. � �.
„
Owner's Name: r prxt�r "
Owner's Address!' 11
Da a of Inspection:
Dame of Inspector: (please print)
,, ',Company Name �.,_ ,
� °` ailin �ddress`t�
Telephone Dumber: - 7
CERT'IFTCA`TiO ` TATEM' ENT
r r �.r
I Cent y thht I have'personally`inspected the sewage disposal s ern at is address and tha the info nation
tbeloA �is'ttuei�accurate and complete,as of the time of the inspection,The inspection was performe�d�based,d y�� �h,r
t t d 1
traLting an exper ence,n the propq functiarn attd maintenance of site sewage disposal system5,���in���
apinrovd system ihspctor pursuant to,section I5.340 of Title S(;110 C(VII 15.000). The system,r�i«,1
f , Passes 1 lt „�1i"6tiftrtt� 1tCita' .3
a
Conditionally Passes
Needs Further Evaluation lay the Local Approving Authority "t ° �� F "
Fails
ter�1 y f,"1r� .CA�1 , , R ,"�.. j, �f, �� t, „r, �,» 1101
';' �spectoM,s Signature: � �� � ,,, ��p, _ Date:
�
5 + 1, iv!,le 8�4{4;i a��m�r
inspector shall submit a co ofthis.inspection report to the Approving Authority'() o`ard ofl eal
p copy p p Pi g ,
�� a y L7 P)WithSrt 3p days of completing this inspection.If the system is a shared system or has a design 416W;6fa�
, � g, p gpd or greater,tlte�ianspcctor and the,system owner shall submit the report to the appropriate regiona,o�di,,6
> i'�T}ne original should be sent to the system owner and copies sent to the buyer,if applicable,anathe a�►Iir
authority ��
p
b r 4 y, �gi4 uid mitre
NI`�te5 hnd Comments,0
QW
es
( � k r
r�a F hY ro
,*,This report only describes conditions at the time of inspection and under the conditions
�� � tlme;T'his`lns Inspection does not address ow the system will perform Ili the future under the samo 01
p h y 1
A A ID-0 V66
ca�nnditions`of uses
�`��v Title 5 Inspection Form 6/15/2000 page 1
, A R
ley r r uM1 S
OFFICIAL CAL I PEC 'ION FORM NOT FOR VOLUNTARY ASSESSMENTS
r.
"SUBSURFACE SEWAGE I a D— ISPOSAL SYSTEM INSPECTION 'C
PAdT A
r
CERTIFICATION (Cow inmcd
,
Property�,Address:-
�
Z) r A" kkl k y d
rp « D lie of%nspectiori:
C'Inspection Summary: Check A,R,C,D or] / I,A"Ys cornplete all of Section D
A.,:,System Posses:A5,3 ..
r
have not found any information which indicates that any of`the failure criteria described iaa 3l0 CMR
3 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
y; x� � r�r'f
Corriments" ". ,
44
a" " System�Conditiontilly Passes:
04e or more system components as described in the"Conditional Pass"section need to be replaced
" ) t a y
repaired,"fhe system,upon completion of the replacement or repair,as approved by the Board ofliealth,
a ?�
� ,^ .-r .•�, .d;. - ,; ! ���k k�>r riG'� �ar`�fl as r r
r AtisWer,yes,no or not determined(Y,N,NI7)in tiro for fire fcr`Ilowiri statements.If"not determined"pleas
h r 1 y N
explain t � t "�' k
A �, q�y r a sf�{ C�t%"Y�P1 r iltiti�l itii 1r ;r1rl qi r b a ��� {
a�
x" , ,W °GTE se i �"r'r�etal a,Ad over`20 years old*or the septic tank(whether metal or not)is str��tttr�ii�
+ � "'tin Syr r
t fl� 1 1 .,- wy 1�1a55
s)UnU eA (ts substantial ni l6ratibn or'ex ltxation or tanklailure is imminent. stem wit
r r ,„ �rf r a Q ..r..: r " rpl wr,^�drsr
' ,i c>tlst ► kP� replaced Wit C`A complyh g septic tank as approved by the Board ofhit with.
M
Ct l a tycaank.tvlll ass ins e n If itis structurally sound,not leaking and ifa Certificate ofCom rllance ��� r� �r "
� ndlcAtln that the tartlt Is less than 20 years old is available.
a%
pd n Y tr, r r w a rk , yk
wPt���y �
4iyi .�Y�"^G�w;��°�en'a"`
/' ! rrsrriiis r s f br�fi r,, 1, i rNIQ
P pIV1 explain i 6fk i � fUg�A
rvn
y ,� Wa>N@'�y" 1
a`/+
�; Observation of sewage backup or break out or high static water level in the distribution box dud
"H 1R p °O r
"R obstttucted l e s o"due.to,a broken;settled or uneven distribution box, System will pass inspectionrip
k pI" ) '�
er r `a t&al of Board of Health):
r'ft/i Mxr tldt1"r�iir'tt(lr broken{ry�i�ryJe(s are replaced
S ) ,,t tlr 'C A l ) p
` f r
t f�f;s�J i � 1'N"�s.r��"�,�`�,,...`�.w �.`y 0�1St1°uetiOn is removed
distribution box is leveled or replaced e<a y�ptttit r "
t`Yf
P� l � t s ;r l ?g7� tier
� �N➢1p�"1� �rp 6r� r h xJ' d�l e r I � .. (� �r� / l
w y�4�d �ad�i�,����i �k",��9�r'�f. Y ✓� ' 74 � F� o
system requited pumping more than 4 times a year due to broken or obstructed pipes)
r ass
Inspection If with a royal ofthe Board ofHealth y d ti.
p ( �p Ir ��
�A4
broken pipe(s)are replaced
r �fl Ps r obstruction is removed
t� explain" r
m
�
y ay�fl flatrl' r h,
rf�
a r�, ��`r �8•r, a��"�� r , � t, ;r '"r� ,�r� l r^�wa�� y, -
y Ty
Pager of I I
�� )t.,1JitAI � ASSESSMENTS
OFFICIAL,INSPECTION FORM - T FOI
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FOI
PART,A
CE11TIFIC:A'1"ION (con(inncd)
Property Address, m
t wrier: 1 t _
—Aq`
Date''of inspection: _ �a•q,,t
C,'; urther valuation is Required by the Board iif llcalth:
Conditions exist which require further evaluatiortby the Board of ilealth in order to determine if"the system t�;X1
T is falling to protect public health,safety or the environiin, nt.
T,
System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that
,,/ s' em is not.functioning in a manner which will protect public health,safety and the envlronment'," M�: �.
a. �.
;Cesspoo�l,or privy is`within 50 feet of a surface water„
Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh ��
a. zWA„bl e{d'+4
y ystem wlll fall unless the Board of Health(and l ul)llrr Water Supplier,if any)determines that they
bystem Is' tloning In a manner,that protects the public health,safety and environment-"d"''t��
„FFn ✓ �rtp� /�'�f2/`y�� ik
,�
� �,�� The system.haswa,septic tank and soil absorption system(SAS)and the SAS is within 100�feet"ofa� a ` �
surface,water;`sttpply or tributary,to a surface water supply.
d � r�� ,;✓�rwtl,��6""Y'iK�'� m.G ��$.kJ.;ys6� , "r�iw � a'fF,urt; �,,;N,. ,�vvgii �gR,yr
i�he s stem`lias septic tank an0AS and the SAS is within a Zone l of public water supply,
r�y�
M A � p
"w , ` f ,`T`he system has a septic tank and SAS and the SAS is within 50 feet of private water supl �weli
_ l"he system has,a septic tank and SAS and the SAS is less than 100 feet but 50 feet of ntoxe froin a
o R �. � ��°� pie ��+ p + rAl, p I� pp yR, ell .l Method used t0 determine distance �!! Pro q,",'� �/� � '�dil7gw"
C'�B f iF� �lq Aid? ne,� XXM at4 wNtWr�Snr. 14 w '1k, ���fJ
i rrt ,r i4 u Y w ,rv;y Rre, *s, _.....
6
.� . . s
system passes if the well water analysis,performed at a T71F'certified laboratory, for
" �"' .' i x^,d J
x xr7 bo6terlh"and V61atile�ork,i tic compounds indicates that the well is free from pollution firom thaf'f>icility
p timmoitia At ogen and nitrate nitrogen is equal to or less than 5 pprii,provided
the presence of
faliuWcriterlA are triggered.��A copy of the analysis must be attached to this form.,
ix� vC4 �r1f✓s�" °dd1fYi�
r r a r g lM1 i� p
E r�
P �..�f'kjYr;l'✓ � y/ 0 +" � .. ,................... srr�lt>�.�'mii'fi „ r ,�Rai
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i � page 4 of 11
s �� ' � �� VOLUNTARY ASSESSMENTS OFFI IAA INSPECT IO FOR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Fr'
PART A
C:,"E101FICATION (con(inuc(l)
Property Address: �5 " ,
Owner2
. Dateof Inspection:
� p
► t�►tt�9r rt' «;
;lD.,`„System Failure Criteria applicable to all systems:
"you mus indicate"yes”,or"no",to each of the folloN�lhig for fill inspections: � '
of i "i IYy ��ky rtr��i dM1�
w Yes No '
A,Backupof sewage Into facility or system component due to overloaded or clogged SAS or`cesspbolri��, �
i�Discharge:,ar,panding,ofeffluent to the surface of tide ground or surface waters due to an overloaded be
�F clogged SAS or cesspool
Static liquid level in tiie distribution box above outlet invert due to ate overloaded or clogged SAS or
cesspool
,Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day,flow ,
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).dumber
,N ;of times pumped
Any portion,of tile 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 it surface' y� �"`
d .� �
u -
Any portion of a cesspool or privy is within a Zone 1 ofa public well. tttt
%Any portion ofa,cesspool or privy within 50 feet of private water supply well.
, M Y y i t" t Y J
por i n of a cesspool or privy is less tlrair 100 feet but greater than 50 feet from alpriVate watt
su l "well with no acceptable water quality analysis. This system asses if the well.w"aier andl
p pp Y, p q Y Y C Y p �
t
performed at a DEP certified laboratory,for col iforin bacteria and volatile organic i�inmpotartt sk, ►i'k�'n*;° 4 "
f y nitraaen arhtd�orate p y p arti�trania�
nitrogen is equal to or less than i in provided presence o of e
l is,ft free barn pollution from that facility and tier,
idetl that no other failure criteria; �F�
df � g b � q pp in,
are trlggered,:A copy of the analysis must be attached t0 this farm.]
x d rrry 9
(fit~ a) t►e system fiMs.�l leave determined that one or more of the above failure criterit�c",�st asp
" %� ` „►'� ;;d toed ha 31U,CMtlS,3g3'therefore the system fails. The system owner should contact the
�
cessary to correct the failure,
�A ealtlt to determine what will be tie c
VMr
",gig iii°p IFr P ' 1tly�# � i � � tr
Wit; ►i �'�4ti611911,ytA£Cil "tit rr '4%�1����1^' '., 1► ` i ' I Glv`Ft' lF �,�n � ���r,'f"'9t9 i,
r �+ „d 5
q°y ,''iLarge,1'9yste njsl,A'>4r�►"l`i;�`T,7y,�li rl,,l �.',��y,, �,', rr, ,.r °.7 4 ►��% r �,;y,t�q k' "" "dry° �.,
"ry6 a considered a large system the system must serve a facility with a design flow of 16,000'' d to
tr'
ro� ry;Y 66nust!indicate either"yes"or,,"no"to each of the fallowing:
(A7
4 I
e followlah criteria apply to lar a systems in addition to the criteria above)
!I
9: her f. WrNI a 4 '✓yF }aa
system is within 400 feet of a surface drinking water supply ° `
system is within 200 c feet of a tributary to a surface drinking water supplyf
7
i �` rK l okra
?
system'is located 1n a nitrogen sensitive area(bite We l rotection Area IWPA or a e gip,
11 ofa public water supply well
Ott a��rt 3 �,r i� fi , lf�r n d 1
a � if nu have answere►dy" es"to any,i t question in Section l"the system is considered a sign threat)ry/ e
a i r i
y � y� g gar�a� �
,► ,,
S. section 1D abava the largd'rsystem has failed.The owner or operator of ally large system con idered tai(hr,r
fhei it threat under Section tor failed under Section D shall
upgrade the system in accbrdancewr�l►eirn 1
04 r The s y sten owner should contact th e a pp ro p riate regional
office of Department.'
i
4 r r��,r� r.
P4 Y �,�,� ✓ � � 4
a.' Piigc 5 of�l l
C Ff I "CIO ➢+ORS� f FOR V����I11 �" ��Y ASSESSMENTS
' DISPOSAL SVSTEM INSPECTION FORM
SUBSURFACE SEWAGE
C H E'1,,,.1 .1.i 1 �9•y
9
Property Address:
,r fawner: / � � � �, ,.r,�t r
1
.`lC)atnteof Inspection: �° �"� 6
Check if the followinry have been done. You must indicatF.�XesLor"ndas to each of the followin
�.
Yes No
Pumping information was provided by the owner, occupant,or Board of Health s1
Were any of the system components pumped out in the previous two weeks?
flas the�system received normal flows in the previous two week period?
Have large volumes ofwater been introduced to the system recently or as part ofthis inspection 7
Were as built plans of the system obtained and examined?(If they were not available note as N
d
�f
Was the facility or dwelling Inspected for signs o("sewage back up
Was the site inspected for signs of break out 7
Were all s stern corn i k
y portents,excluding sire SAS, located atr site 7 ��„,��t��� �,�, � ✓��k����� a
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
oft a baffles or tees,'material of construction,dimensions, depth of liquid,depth ofsludge and depth!ofsctu��� � �`��x✓%” pt �
_ Was the`�faciliry owner(and occupants,if different front owner)provided with information oil tlterope �k�% >'
�� maintenance of subsurface sewage disposal systems?
11 ✓a " pp
s' o
v �k
� x �nr 'h the size and location of the Soil Absorption System (SAS)oil the site has been determlri�d`base r. t
X44 Existing information.For example,
mm �e3 r
N'Wf F dpi 1 1 y f , i 4 p, ✓ '4"yl
g 4t plan at the Board of Health.
{�✓Pktix✓trriro s F
r l7etermin-ed in the field(if any of the failure criteria related to part.0 is at issue approxirri tiorn o assn
irr►acceptable)1316 CM[R 15.30(3)(b)]
� ���s
,
r
e✓ i54 "a urt"; www„ ✓, r I
" �t�r .✓ 6411 kr v l�� r 4atN �.
f " om' " f's�� v' I R Irk✓ u
c, � / y ,ti ew�
d �tAd� n ^ Fit �F
V
, pI e� ,i�
r1✓�g1� JaU� s- a ,
�� 9✓
�i� ✓� i ,!, ��� �✓ a
At �
Page Ci of 11 r f
OFFICIM.
SUBSURFACE SEWAGE DISPOSAL SYS"YEM INSPECTION FORM
PA RTC
C
S'l'h:1"VI INFORNIA 1'1ON
]Property Address: p f � y IY�
e „w:wmur ^n're'G � � d
Owner: -
Date".of Inspection. ,��R �� � � a ►a �,s t
�
FLOW COIWPITION,13
RESIDENTIAL,
Numberofbedrooms,(design):, �_" Number of bedrooms(actual);
h I7 ICaN;ft6ww` used on 3l0 C;MR 5,203 (for exatnple: 110 gpd x 0 of bedroorns):
�r �Numk�er a�fcurrenkresrdertts: ,�� .�'.. �
Does residence
have a garbage grind��(yes r no .:�'
Is laundry on a separate sewage syste (yes ono . [if yes separate inspection required)
Laltitdr 'system inspected(yes or no):
reading atlable(last� ! a use: es� t 2 ca rs usa�e �d '�eason ( (y Water meter ( Y (gl' )) �.�(p ,fie
Sump pump(yes or no) t
Last date of occupancy,
COMMERCLAL/I I'RL�L,
1US
�� ', l" d ofeskablishment,k� � p, I'� � �
���o /� ,, �F "kn�11 M
( Syr , h Deslgn fl6yv(based on 310 MICA 15.203) __�.��_.....__.Ci7(y �� ��
,.,�
" ?��`
Care se trap present(yesrtro)»'
Indu(strlat��aste`h6lding Lank present(yes or no):
",rx "�� n Non 5a11tt�waste`dlscharged to the Title 5 system(yes or no):
l'"k�r� ., � W Ater meter reading'y if availablk':�
x ^ °
Last date,ofoccupancy/use a P �
�w t
� "/ � 4 tk ��,Rr6 � �"� , /k"Af;;rc��ra k��$r>S"r"✓N �'�"tl�k"
i , - , o"S ,s i ri ff ,« ►,,r►d°rx4a;► �GE1°ER L,INFORMATION "i kw,r ��/�,✓e�1'"���rrl���F , c
► '�I�"�`1`���d�� i`.�1�lnpin�ReCOI(1$ f,�,, "" � A� ��� '9��i�����"� ��' � ��1�"'1!
dy✓'J"FA�� "r+�l ► f" k ". a .w++ w+'-0d ' y /P� l N l�
GUvlvAtliG � �+ � '✓/ � � i�l� a��,
� r ��, �kglWas system pumped as part of the inspection(yes tto): �. � � � � k�n�✓! "��
nlTl ed. iillons��•How was
► t►Itt aed deter171ined'�
p , p y p l
PiDv 1lrilufl
gran
rp� yw�w�/ !ry�q��g'q;
�,NkNn kir ¢ l T.l A'r�l['kl k7la73A�A`YE
e t►c,tank distribution'box soil absorption system
S#ngle'eesspoah
��o'vef low ces$ ooi
p 8,� t
Pr Ivy,9
ystem,(yas or no)(ifyes$attach previous inspection records, if any) ���,d�,w',v'� "�� � ��� �'�►�
finti6ative/Alternattive;(echnology;Attach a copy of the current operation and maintenance contraet to
lied iu s stern owner b
lrar �k W �i kv � /
yN
" h r , y of the DE approval
r �h !✓F h
tg��tank A,ttach a cop
9n� G,�ur<���'r�,k /k�� N 9'7 i ¢ r D ✓�, � i ��e Jh7�i
Other(describe)..
r .Gr, ,1
i✓ y p g ) ce of information:
A , oxamake age Of all come ncu s date stalled f lo�vn rd sour
�;
��N�t� h���� ✓ "� ��/f i N i � a-_____�........�..,...... „>a Fhb � 'f �y !�iV rot"�rv�!
SIY
� � u �� r� F�9 1„�r�, " 'F a° � rm+�w'� ���F r ,,, `,§e"r � ak� Mr!%}k•°
�i a Were sewage odors detected wltenarriving'at the site(yes o► no)
r
sky✓x raw x 4 r' w�w✓�.,""��r�. � ry* rp� � 6�.
h
o 2N
�/ Mk
v r "a� y9�"N✓"�k' y �e, f M$ 4 of
t _
Jm Il,
V%r,
page 7 of l �.
OFFICIAL INSPECTION FOItM NOT FOR VOi..[1N'I".CRY ASSESSMENTS"
SUBSURFACE SEWAGE DISPOSAL SYSTE'M INSPECTION FORM
PART C
SYSTEM INFORMATION (cominuc(l)
Property Address 2, n A� ��
, ua N � 7T�'° ,F
y
Owner: •,�"r s r��r,�
DaWof Inspections
,
BUILDING SEWER(locate on site plan)
W�
Deptlt below grade:
a Materials of COttstrtlCtlonr" CS1St lion ( 1'VC other(explain).
�'.)�►isteunce from private,water,supply well or suction lute:
Comments`(on condition ofjoints,venting evidence of leakage,etc.):
w "w
4
� " r, � Sttl pfd*r118�
SEPTIC TANK: (locate on site plan) � i rrr w�rl
=ar a q g
a r
Depth below grade.
w w `Makenal ofconstruction concrete metal _ fiberglass
--polyethylene ,
°F lltakFls md�k� lrll1sk u�el is age coal"rrrttcd It a Certificate ofl Compliance c5 or no):
(attach»r rA
I a copy
y 1 (yes
,r v rw rFa�eeI�Pnsloils
ca D i .r
Sludge depth:'�� r�✓ ���F "
IV ltstnnce from top ofsl e to bottom of outlet tee oa•baffle;_�_ ; a», C l,f .}�f
i i °i0f j ` I""�"{` Aga l"�tt 1�Yr ✓d :r
Scutri, ekh"a ss °r,h1
y;T)ts nce from b ttoi .pfsctumto bottorrt ofoutlett tee or baffle:
u�r
✓� � „ 4� �'Jk jdnfu��n 3^ 1n Frw��dn
r
+ �
w
IiUt (Were dimensions",determhtedr.
w � .,� <✓r,k y';yrttNrfya? r
CotrimettCs(ntt pttmpr recommendations,'ittle
� _ or baffle cartdi t n structural uttc tt li utd l Veld �� ` �
�� as belated to'outlet`iatvert,evidenc ofle;aka e,etc,):outlet tee � ��
e �`
r P1i r ✓r p p
6, ``
4 r�,� r4A xwE �� r�f � Rr¢;+. tw1� � p^ �� °�i'.. / Y �. °,�.. �,TM""' �.� 7/'� r �p a' d ��� ✓y�.�'�Gw
4 ai, r � ASI�TIlI' (locate on site plan)
,r err x✓sC�k4
axe "
�
,,1�epthbelowr"grade ._
r a Material of construction concrete metal fiberglass ltolyethyleate other
r ✓�� �"� "r��f�' "�7��fI�A 4�A� I���2 °� r� r� �� � ` � pia�l � R !,� n��+t��,Nr�{rr%a
�'��� II�t�d � � ��rf 2 i, s t r� p� � � / �'�' ✓�'v�un� 4
F I�✓ ,r T ✓ �J ,/ R 4k v"
✓ ✓ �r, teor Cop a °scum to Cop u(outlet tee or baffles
r ls�ce O -baptt f outlet tee or baffle:
�� ✓ �1� � �
bottom of
a o�last um in v,1r4,�✓ i;v
Cor►ttrtauts on um "i t recomtuendations, ��R�✓ ,7 i�
r
�4rd ( p p g inlet and outlet tee or baffle condition,structural uttegrrtya liquid 1 4fn
late,to outlet hivgt,evidence ofleakage,etc.):
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OFFICIA1, INSPECTION FORM—INOTFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL sys'rEM INSPE riON FORM
A LRT C '
Y TEIM INFORMATION (continued)
,TProperty Address � S T��,Yo.
,dwner:°' .
,!,Date of Inspection: E I <
f .� __ � ��t „ bt,:tt
TIGHT or HOLDING TANK:_ (tank must be pumped at time of inspection)(locate on site plan)
Depth below�grade: � rr 1�,,•1 Rla,,;a�
'Material of construction: concrete metal fiberglass_ _ jolyethylene other(explain):
� `,,.;�f W"Umensions: f°3(dl l
dapacity: allon�
Design Flow.
,9allons/day
�� tie a hr rt present(yes or no): .
Al m level �'� � Alarm in working order(yes C7C no):
R —
`Date of last pumping:
, ornments(condition of alarm and float switches,etc.): Mks;. Ata �lFtgq ,t i °'
R ,p
f �.w rr �. wa....,m...�,� W..a. .«..w,.....,.....»...,..,.,.�...,........................�,..,.,.......,.,...»,.....»,«...........,.,......,.,.,,.,.............,w...,,»,,....,....,,.,.,,«..,...,,..,......,,........,... w ,.e 'k Y WP
i
DISTRIBUTION BOX,- &ifpresent must be opened)(locate on site plan) ntr�taf�'tf fit �,'
r liepth'cif liquid level above outlet invert: °r ��
in'to r out s level and distribution to outlets equal,any evidence of solids carryover,arty evide
Way' �Cornnaents note�if box ox is
ett"vr : �; ,am�n� k n' "y t
� ✓,...:. :." e u�G " ` M11
IAMT3�;R: (locate on site plan)
�l R b
1 WInp3 in working order(yes or no):
,lannS ln`working,order(yes or no):
f
omumenks(note condition of pump chamber,condition of pumps and appurtenances,etc.)
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V page 9 of l l
OFFICIAL,INSPECTION FORM NOTFOR VOLUNTARY ASSESSMENTS-,
suBsuRr
PART
SYSTEM If FOR ATIM (continuc(l)
A
Property Address: m
Owners
Date of Inspection:
SOIL,ABSORPTION SYSTEM(SAS): (locate oaa site plan,excavation not required)
�.,
If SAS not louated'explain why:
Type
leaching pits,number:
r 'teaching chambers,number:
leaching galleries,number:
leaching trendies,number,length:
leaching fields,°Number,dimensions:
t s
overflow cesspool,number: _. -
��, "innovative/alternative system! Type/name of technology.
u ✓ y% oiinnents mote condition of$oil,'signs of hydraulic failure, level of ponding,damp Soil,condition ofvegetatl n���� ✓�� r�x,��m,,� u,,
eto� « i , ✓��
Or
�0— w. � r✓tiJ y 9�� �P ✓�,��� r
m 5 � 1 r p � � � r .�N��✓ rN
CESSPOOLS: (cesspool must be pumped as pail of inspect ion)(locate on site plan)
�`�4Nnmber and configuration
P Depfh top of liquid to inlet invert:
leptb ofsolids layer,,,''
4A./eypy�th fscbm la
V u r l✓`a C _o .......�...._..._.. f a✓ i�`� I r 9
er
y
D mensions o(`cesspool, j,
Matetlals�fcons trttcttonr.
��, r � ' ,�� Gorntents mote conditton ofsoil,`signs afhydraulic failure level ofponding condition of vegetation,
r '�i "' Jar� � 'a fijr r^✓wro r a �� � �'4
y.0 r Y �'y�� fl,�rr✓ ,� ib/'r a
/� X
it ;'A ' c
"�✓ r aa�� 1'a " Ji'�,n �« d
y t x r I' I ' "(locate on site plan)
� ��q, � ✓
Materlals ofconstruction _....W_.
"�� h V�Aa ✓�"' ,r���-lTim,e(nslons��r' � t r y '. it ,�L�� ����� � � 'h 6�,��;y�yal
era " epirlo9olld3i ' i`�i� ✓u3
�
E axF���n � onents(note condition ofsotl,signs ofhychaulic failure, level ofponding,condition of vegetation etc)
�
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�,OFFI IAL INSPECTION FORM —NOTFOR VOLUNTARY ASSESSMEN IS ,
SUBSURFACE SEWAGE DISPOSAL SYSi"IA INSPECTION I'°OItM
PARTC
4� C I'hM l�di�"LIRNI�,'I'ION (continue(l)
a
Property Address:
'Owl
tert
Date,or Inspection: s,
SKETCH OF SEWAGE DISPOSAL SYSTE'M
:4, a
Provide,a'sketch of the sewage disposal system including ties to at least two permanent reference landmarks or�i� �.b<",'�t
✓ �� bettclunarks.Locate all wells within 100 feet, Locate where public'water supply enters the building.
ry a
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l rye[�F i
WyP�dJvN�m�{8 � Lz E
Sol ,.pp
6;J ✓ q..; .. a .. w. �m,mw.a uwwmm.mw iw+ 7m✓d ty !N'N 5"`W J
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OFFICIAL INSPECTION FORM...NOT FOR VOLIJNTARY ASSESSMENTs
`ACE SEWAGE DISI C �AL � �
T .i:;1'W INSPECTION FORM S
PART C:
SYSTEM 11ff0IZMA'I`I0N (cmitinur(l)
Property�.ddress:
Y ,
`. .Owner: t
"Date of Inspection:
SITE EXAM'
Slope '
Surface water
Check cellar
ShalloWv wells
stttnated depth to orotund water feet
a
Please indicate(check)all methods used to determine the high ground water elevation:
".Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checlked with local board of Health-explain:
Checked,with local excavators, installers-(attach documentation)
Accessed USCS database-explain:
` ou established the high gro nd w)ter a levy low-,
g You must escrtbe how g�W
M i C
a,!� ` —...�M� �..,,. � � w�iw t�
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aurnn9ary r'3ecnrU Cram gee. .ed on 113012006 10:48:47 AM by Lisa Warren Page 1
-Fo\/vn of North Aridover
Tax Nk�:ip # 210-1073-0052-0000.0
31 CM
l
N. ANDOVE R, M
01
Class 101 Sint ir; rriPy Prol.mrty`t ype+ 1 Residential
Size Total 1.04 Acres
FY 2006
US Mailing-indox
Name/Address Type Loarr Number Active/Inact, From Until
JENKINS, SUSAN CRONIN Payer
31 GRAY S"1"REET
N. ANDOVER, MA
01845 ,
IUB Account M int.
Account No . Cycle Occupant Name Active/Inactiva
Bldg Id. 137020 -31 GRAY STREET Last Billing Date 11/2/2005
1090380 01 Cycle 01 Active
UB Services maint.
Service Code' Rate Charge Multiplier/users
MISCFEE ADMIN FEE O.63 5/8 7.82 1/
WTR WATER 01 ALL METER SIZE 75.46 /1
UB Motor Maintenance
Serial No Status Location [,rand Type Size YTD Cults
16748930 a Active ERT ? w Water 0,63 0.63 0
Gate Heading Code Consumption Posted Tate Variance
10/26/2005 426 a Actual 22 11/9/"1.006 -13%
7/20/2005 404 a Actual 23 8/10/2005 22%
4/22/2005 381 a Actual 17 5/13/2005 -6%
2/1/2005 364 a Actual 22 2/15/2005 7%
10/2712004 342 a Actual 18 11/15/2004 -19%
8/3/2004 324 a Actual 23 8/25/2004 38%
5/7/2004 301 a Actual 18 6/8/2004 -15%
2/212004 283 a Actual 23 2/24/2004 0%
10/22/2003 260 n New Meter 0 10/22/2003 0%
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