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Miscellaneous - 1 EQUESTRIAN DRIVE 4/30/2018
PR - Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record Form JUL 1 b ?015 TOWN OF NORTH ANDOVER DEP has provided this form for usezby local Boards of HealthFjOth"Gtiisffiay be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name Address (if different from location) Citylrown State — t( {�Zip Telephone Number r B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) aleptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2No If yes, was it cleaned? [:1Yes F1 No 5. Condition of 6: System Pumped By: Neil. Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G L _ Lowell Waste Water F5821 Vehicle License Number 11 Date t5form4.docr 06/03 System Pumping Record • Page 1 of 1 REC21 ED -C\- Commonwealth of Massachusetts City/Town of r fi1z ° �3WNOFNORTHAhD3EiS stem Pum in Record HEALTH DEPR? T MEET Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Le t o , Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address (— F— n U Cityrrown State Zip Code 2. System Owner. Name �J Address (if different from location) City/Town State© [ (— �Z f e Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Iv Ir — ca — 2. Quantity Pumped eptic Tank Date Cesspool(s) 6� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition pff System: fU6 � - 6. System Pumped By: 7. t5form4.doc• 06/03 Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company contents were disposed: Lowell Waste Water Date System Pumping Recons • Page 1 of 1 IL Commonwealth of Massachusetts City/Town of REMPPR . System Pumping Record PPR Form 4 DEP has provided this form for use by local Boards of Health.mi sW(AC6@ ut the information must be substantially the same as that provided he e. BObItH ii' gasform, heck with your local Board of Health to determine the form they use. The System Pumping Recordmus a submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left kgOfront of hour , Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: ` ' 4 &�—� Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Telephone Number — 2. Quantity Pumped Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Q --No If yes, was it cleaned? ❑ Yes ❑ No 5. ConditigUnof tIjl j 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location here contents were disposed: L'S. _ Lowell Waste Water F5821 Vehicle License Number ('(-C�-Ii Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts CitylTown of System Pumping Record y Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be, substantially the same as that provided here. Before using this form, check with your local Board of Health tq determine the form they use. The System Pumping Record must be submitted to the local Board of Health or - approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of hou Ri ht front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address f� uza�oL-� Dri )v NO <-4-k,",- Cityrrown State Zip Code 2. System Owner: Name Address (it ditterent from location) CitylTown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) State Zip Code rooct-- a- s-�;,G Telephone Number — 2. Quantity Pumped Q-Te'pfic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9-14o- If yes, was it cleaned? ❑ Yes ❑ No 5. Condi ion of System: ✓ver-t./L ✓-- A �- x 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed:. G.L.S.D _ Lowell.WastP3NntPr Signature F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record . Page 1 of 1 495� Town of North Andover HEALTH DEPARTMENT CHECK #;I DATE: LOCATION: I R,)Q F -ST K 1,0 j h H/ 0 NAME: C -,S 6 CONTRACTOR NAME: TYRe of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type. $ 0 Funeral Directors $ 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Rocreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco $ 0 TrashlSolid Waste Hauler $- 0 Well Construction $ SEP77C Systems 0 Septic - Soil Testing 0 Septic - Design Approval $ 0 Septic Disposal Works Construction (DWQ $ 13 Septic Disposal Works Installers (DWI) $ 0 Title 5 Inspector $ Or'*'Title 5 Report 0 0 Other (Indicate) $ HeaA,4gent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do,not use the return key. ILEI Commonwealth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary / 1 Equestrian Drive Property Address John Webber Owner's Name North Andover City/Town MA 01845 State Zip Code 10/13/2010 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Aroilla Road Company Address Andover Ma City/Town State 978-475-4786 S115 Telephone Number B. Certification License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the. Local Approving Authority 10/13/2010 InsfectorA SignatuW 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 • 09/08 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner's Name North Andover MA 01845 10/13/2010 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: 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owners Name North Andover MA 01845 10/13/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) 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): El broken pipe(s) are replaced ElY ElN El 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Eauestrian Drive Property Address John Webber Owner's Name North Andover MA 01845 10/13/2010 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 % day flow t5ins - 09/08 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 't 1 Equestrian Drive Property Address John Webber Owner Owner's Name nformation is required for North Andover MA 01845 10/13/2010 for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 i ❑ ® 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 • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 every page. Citylrown State Zip Code C. Checklist 10/13/2010 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner's Name North Andover Cityfrown D. System Information Description: MA 01845 10/13/2010 State Zip Code Date of Inspection Number of current residents: Yes 2 No ❑ Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( Y 9 (gpd))� Yes Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner information is required for every page. Owner's Name North Andover MA 01845 10/13/2010 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: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Pumped 2008, owner 1500 gallons Measured tank Inspect tank 8r tees ® Yes ❑ No ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 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 1 Equestrian Drive Property Address John Webber Owner information is required for every page. Owner's Name North Andover MA 01845 10/13/2010 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 21 years old, 8/28/1989, as built plan Were sewage odors detected when arriving at the site? s Building Sewer (locate on site plan): Depth below grade: Material of construction: 3 feet ® cast iron ❑ 40 PVC ❑ other .(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron thru wall. 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: 2.5 feet ❑ Yes ® No ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list ager years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x5'x4 Sludge depth: 1" ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 10/13/2010 every page. Cityrrown 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 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 19" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank.Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • 09108 feet ❑ polyethylene ❑ other (explain): Date 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 1 Equestrian Drive Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 10/13/2010 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: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 10/13/2010 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert I Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. No evidence of carryover. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 09/08 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 1 Equestrian Drive ,p Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 10/13/2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions. 1 field 40'x 40' ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No evidence of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth – top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code E 10/13/2010 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1 Equestrian Drive Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 10/13/2010 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 I t�A� I®( `- C__ -}-\z_ _ "5jl L J i e t5ins • 09108 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Equestrian Drive Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 10/13/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t5ins • 09/06 Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/28/1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 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 1 Equestrian Drive Property Address John Webber Owner Owner's Name information is required for North Andover MA 01845 10/13/2010 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 10/13/2010 9:30:53 AM by Karen Hanlon Town of North Andover Tax Map # 210-105.D-0149-0000.0 Parcel Id 17108 1 EQUESTRIAN DRIVE WEBBER JOHN T 1 EQUESTRIAN DRIVE N. ANDOVER, MA 01845 Class 101 Single Family Property Type Size Total 1 Acres FY 2011 Page ' 1 Residentia UB Mailing Index Name/Address Type Loan Number Active/lnact. From Unti WEBBER JOHN T Payor 1 EQUESTRIAN DRIVE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 1752,7.0 - 1 EQUESTRIAN DRIVE Last Billing Date 10/7/2010 3170197 03 Cycle 03 Active UB Services Maint. Account No. 3170197 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 761.51 /1 UB Meter Maintenance Account No. 3170197 Serial No Status Location Brand Type Size YTD Con,, 13240255 a Active ERT HH METE METE w Water 1 1 49: Date Reading Code Consumption Posted Date Variance 9/13/2010 1144 a Actual 144 10/15/2010 4940X 6/7/2010 1000 a Actual 22 7/15/2010 -210/1 3/10/2010 978 a Actual 28 4/14/2010 -190/ 12/10/2009 950 a Actual 35 1/12/2010 -44°/ 9/10/2009 915 a Actual 64 10/15/2009 50% 6/8/2009 851 a Actual 40 7/20/2009 1250/ 3/12/2009 811 a Actual 19 4/29/2009 -27°/ 12/8/2008 792 a Actual 25 1/20/2009 -720/ 9/9/2008 767 a Actual 95 10/10/2008 305°/ 6/5/2008 672 a Actual 21 7/16/2008 18°/ 3/11/2008 651 a Actual 19 4/11/2008 -43°/ 12/10/2007 632 a Actual 35 1/22/2008 -58°/ 9/5/2007 597 a Actual 71 10/12/2007 307°/ 6/15/2007 526 a Actual 20 7/20/2007 20/ 3/13/2007 506 a Actual 19 4/16/2007 0°/ 12/12/2006 487 a Actual 19 1/19/2007 -720/ 9/12/2006 468 a Actual 67 10/20/2006 1920/ 6/13/2006 401 aActual 25 7/10/2006 -410/ 3/6/2006 376 a Actual 32 4/17/2006 10X 12/21/2005 344 a Actual 39 1/17/2006 -540 Trouble Code:03 9/20/2005 305 a Actual 92 10/14/2005 104° Trouble Code:03 6/13/2005 213 a Actual 41 7/15/2005 -3°/ 3/15/2005 172 a Actual 43 4/5/2005 37°/ 12/13/2004 129 a Actual 30 1/14/2005 -490/ 3626 Town of North Andover HEALTH DEPARTMENT CHU CHECK#: DATE,. I /1V LOCATION: H/0 NAME: CONTRACTOR NAME-,-�e// jy2e of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $- 0 Food Service - Type: $ 0 Funeral Directors $ 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco $ 0 TrashlSolid Waste Hauler $- 11 Well Construction $ SEP77C System 0 Septic - Soil Testing $ 0 Septic - Design Approval 0 Septic Disposal Works Construction (DWC) 0 Septic Disposal Works Installers (DW[) $ 0 Title 5 Inspector $ Pl-'Title 5 Report $ 13 Othen (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _1 Equestrian Drive _ —North Andover_ Owner's Name: _John Webber _ Owner's Address: _1 Equestrian Drive _ North Andover, MA 01845 Date of Inspection: _11/1/2008 Name of Inspector: _Neil J. Bateson Company Name: _Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810_ Telephone Number: _ (978) 475-4786 RECEIVED NOV 13 2008 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority \ F s - Inspector's Signature: Date: _11/1/2008 _ 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. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _1 Equestrian Drive _ _ North Andover— Owner: _ Webber_ Date of Inspection: _11/1/2008 _ Inspection Summary: Check A, B, C, D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. _ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _1 Equestrian Drive _ North Andover— Owner: _Webber Date of Inspection: _11/1/2008 _ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _1 Equestrian Drive_ _ North Andover— Owner: _Webber_ Date of Inspection: —11/1/2008 _ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6" below invert or available volume is 'h day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No— Any portion of the SAS, cesspool or privy is below high ground water elevation. —No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone I of a public well. _No— Any portion of a cesspool or privy is within 50 feet of a private water supply well. —No— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _1 Equestrian Drive _ _ North Andover _ Owner: _Webber_ Date of Inspection: _11/l/2008_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No _Yes _ Pumping information was provided by the owner, occupant, or Board of Health _No_ Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? — _No_ Have large volumes of water been introduced to the system recently or as part of this inspection? Yes — Were as built plans of the system obtained and examined? _Yes_ — Was the facility or dwelling inspected for signs of sewage back up ? Yes_ _ Was the site inspected for signs of break out ? _Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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? _Yes_ , Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No _Yes_ Existing information. _Yes_ , Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 Equestrian Drive_ _ North Andover– Owner: _Webber Date of Inspection: _11/1/2008_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4 _ Number of bedrooms (actual): _5_ DESIGN flow based on 310 CMR 15.203 _600 _ Number of current residents: _2 Does residence have a garbage grinder (yes or no): Yes _ Is laundry on a separate sewage system (yes or no): _No _ Laundry system inspected (yes or no): _ Seasonal use: (yes or no): _No_ Water meter reading: _Yes _ Sump pump (yes or no): _No_ Last date of occupancy: , Current _ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _gpd Basis of design flow (seats/persons/sgft,etc.): — Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: _ Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped last year, owner _ Was system pumped as part of the inspection (yes or no): _ Yes_ If yes, volume pumped: _1500_ gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: Inspect tank & tee_ TYPE OF SYSTEM _X_ Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): _ _ Approximate age of all components, date installed (if known) and source of information _19 years old, 8/28/1989, as built plan, _ Were sewage odors detected when arriving at the site (yes or no): _No_ Title 5 Inspection Form 6/15/2000 6 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1 Equestrian Drive _ North Andover _ Owner: _Webber Date of Inspection: _11/1/2008_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: 36" Materials of construction: _X_ cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" Cast iron thru wall, 3" PVC in house, no leaks visible SEPTIC TANK: X Depth below grade: _216" _ Material of construction: X_ concrete _ metal —fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: _10' x 5 x 4' Sludge depth: _ 2 _ Distance from top of sludge to bottom of outlet tee or baffle: 25"_ Scum thickness: Distance from top of scum to top of outlet tee or baffle: - 8" -Distance from bottom of scum to bottom of outlet tee or baffle: 19"_ How were dimensions determined: _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. _ Pumped septic tank. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Title 5 Inspection Form 6/15/2000 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1 Equestrian Drive _ North Andover_ Owner: _Webber_ Date of Inspection: _11/1/2008 _ 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/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX_X_ Depth below grade 36" _ Depth of liquid level above outlet invert: _0 _ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc. _D -box level & distribution equal. No evidence of leakage. No evidence of carryover. D -box cover broken, replaced it._ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): — Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Title 5 Inspection Form 6/15/2000 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1 Equestrian Drive _ North Andover— Owner: _Webber_ Date of Inspection: _11/1/2008_ SOIL ABSORPTION SYSTEM (SAS): _X_ (locate on site plan, excavation not required) If SAS not located explain why: Type _ Leaching pits, number: _ Leaching chambers, number: Leaching galleries, number: _ Leaching trench, number, length: Leaching field, number, dimensions: _1 field 40' x 401 _ Overflow cesspool, number: Innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _ Soil ok. Vegetation ok. No sign of ponding to surface. _ CESSPOOLS: Number and configuration: _ Depth — top of liquid to inlet invert: Depth of sludge layer: Depth of scum layer: _ Dimensions of cesspool: _ Materials of construction: Indication of groundwater inflow (yes or no): — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Inspection Form 6/15/2000 El . Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _1 Equestrian Drive _ North Andover— Owner: _Webber Date of Inspection: _11/1/2008_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building House V A to Tank = 38' 10" A to D -Box = 5118" B to Tank = 3011" B to D -Box = 39'3" Q Driveway 1 Water Meter Title 5 Inspection Form 6/15/2000 10 . Page 11 of 11 ' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1 Equestrian Drive _ _ North Andover— Owner: _Webber_ Date of Inspection: _11/1/2008 _ SITE EXAM Slope _ No _ Surface water _ No _ Check cellar _ Yes _ Shallow wells No Estimated depth to ground water _ 4'_ Please indicate (check) all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _5/28/1985_ 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: As per design plan_ Title 5 Inspection Form 6/15/2000 11 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: D —' Lowell Waste Water F 5821 Vehicle license Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts CitylTown of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear, left side of house. Rightfron right rear, right sid of house forms on the computer, use only the tab key to move Address v q �,`�\ u t �Gf�"`I �``"�� y��: � ,{ your cursor - do not use the return Cityfrown State Zip Code key. - . 2 System Owner: We Name Address (if different from location) Cityrrown State �` Q �Zip Code Telephone Number B. Pumping Record l 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: El Cesspool(s) eptic Tank Tight Tank [� Other (describe): 4. Effluent Tee Filter present? 0 Yes �o If yes, was it cleaned? 0 Yes 0 No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: D —' Lowell Waste Water F 5821 Vehicle license Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 1 Equestrian Drive, North Andover Owner: Webber Date of Inspection: 11/1/2008 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. ffld)�6Ax7v,- Neil J. Bateson Bateson Enterprises, Inc. Commonwealth of Massachusetts �;E- L City/Town of � System Pumping Record SEP 5 200 �Form 4 TOWN OF N: ,RT;4 A,' )OVER DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ ISI 1. System Location: V a Address ,�, ll Citylrown Stat 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): JFWA' "MALmov, I Sti Code Telephone Number `l .-4 -o Date . Quantity Pumped: 1 1� Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By ^ tT Name Vehicle License Number Company 7. t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 TOWN OF � SYSTEM DATE: ' rests- d 5 SYSTEM OWNER & ADDRESS 1 u `t S� (` CWv G RECORD RECEIVED Y 3 1 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM LOCATION (example: left front of house) r,' Ik+ -"OJ I �ftks-c Qr• DATE OF PUMPING: ` I u— 0,5 QUANTTI'Y PUMPED : (_�pZa GAL ONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACYOULD RUNBACK FLOODED OTIIER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: q -,2-a, W,Cbbrrl (example: left front of house) DATE OF PUMPING6 ' QUANTITY PUMPED CESSPOOL: NO YES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER GALLONS YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: :Zd4 SOyl,- � COMMENTS: CONTENTS TRANSFERRED TO: r ) S 0 a a 71 m rn V 0 CD S� LA a _i O "h I Qi tD (D � n v o v 0 A O CQ Q O D -h D a' IIsi r'�r V) I O Q O >om �; rr m 3 0 I m 1 o m mCtv o mKo I r. a V c 3 of 3 m 0► j 3 0 3 rt o a i o a 7 0 a a 71 m rn V 0 CD S� LA a _i O "h I Qi tD (D 1'l/il.i[ H - vr k.041 r.. +v ..._..�... Coll ut,un%jealilt of massachusetts , Massachusetts ��yster�c 1'ui�tl� t'ecurd }Ram ooa ion A�e )WN OF NORTH ANDOVE BOARD OF HEALTH E2195 Dote of t'umping Iz— 13 " Quantlt; 1'umtied. 1 f Q 0 Cesspool: No , Yes u Crrilir 'rn,,L-, K1- Yes System � tent Pum ted by: License Contents transferred to:. G �- S Date t inspector 1. TOWN OF j1i• �nQr���' SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS Ulf 5�vl' a { 6 SYSTEM LOCATION (example: left front of house) C t" 1--k— ovi 0 0'st DATE OF PUMPING: QUANTITY PUMPED: �cJ 0 () GALLONS CESSPOOL: NO YES S C TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: 10 e NEW ENGLAND ENGIIc EERING SERVICES August 22, 2000 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 1 Equestrian Drive, North Andover Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The systemap ssed our inspection. If there are any questions please call me at my office, 686-1768. Sincerely c� Benda C. Osgoo1., E.I.T. President 24 - 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAInS , DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5° OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY A$SESSMEN�S SUBSURFjACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: I Fa j tss i Ri,9, / I2121 vE Owner's Name: V14VC-4'.vT ; H E -I -FR icM Owner's Address:__/QvC-'ST2iA�/ /1/'v 1'14 A ^J f-�> o C 2 Date of Inspection: 8 U000 Name of Inspector: (please print) Company Name: CN(,-/..�n�D EN(rl,vt'wQIVG- Mailing Address: _&u 3EL C/ll,yp��,� �lLcuc Telephone Number: - 97 8 - 6 €3 6-/ 7f, P; , CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 2/fasses I Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 . OFFICIAL INSPECTION FORM-- NOT FOR VOLUNTARY ASSESSMENTS ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTA. CERTIFICATION ('continued) Property Address: 1 Fquestrian Drive; North Andover, MA Dwner: Vincent Helfrich Date of Inspection: 8/21/00 , 'Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D ' A. System Passes: ZI have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be. replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. V Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a .complying septic tank as approved by the Board of Health. *A metal septic tank, will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance ' indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: i Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 ! OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address;_ 1 Equestrian Drive North Andover, MA Owner: Vincent Helfrich Date of Inspection: 8/21/00 C. Further Evaluation is Required by the Board of Healthy Conditions exist which require further evaluation by the Boa/hionder t eterrnine if the system is fa i ' g to protect public health, safety or the environment. 1. S tem will pass unless Board of Health determines in ac0 CMR 15.303(1)(4) that the Sys is not, functioning in a manner which will protect ety and the environment: Ce's ool or privy is within 50 feet of a surface water Cessp 1 or privy is within 50 feet of a bordering vegetsalt marsh 2. System will fail unless the and of Health {an ublic Water Supplier, if any) determines that the , system is functioning in a manner at protects t e public health, safety and environment: _ The system has a septic tank an it sorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a su a water supply. _ The system has a septic tank a SAS and a SAS is within a Zone ' 1 of a public water supply. _ The system has a septic to and SA$ and the S is within 50 feet of a private water supply well. The system has a se p 'c tank and SAS and the SASi is ss than 100 feet but 50 feet or more from a private water supply w **. Method used to de distan **This system pas s if the well water analysis, performed at a DE certified laboratory, for coliform bacteria and vol rle organic compounds indicates that the well is free om pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less an 5 ppm, provided that no other failure crit a are triggered. A copy of the analysis must be attached to this rm. 3. ther: Title 5 Inspection Form 6/15/2000 3 _ ,.--77,7 Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DYSPOSAL SYSTEM INSPECTION FORM ' PART A , CERTIFICATION (continued.) Property Address: 1 Equestrian Drive North Andover, MA Owner: Vincent Helfrich Date of Inspection: 8/21/00 D. System Failure Kriteria 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: V'- Discharge or ponding of effluent,to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool -Z-�Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ' Liquid depth in cesspool is less than 6" below invert or available volume is,less than %Z day flow vRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number - of times pumped _tZ 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. �CAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds' indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] A/D D (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. arge Systems:, To be c 'dered a large system the system must serve a facility with a design flow o ,000 gpd to 15,000 gpd. You must indicate e r "yes" of "no" to each of the following: (The following criteria ap to large systems in addition to the criteria ab yes no _ the system is within 400 feet of a s ace drinkin ater supply the system is within 200 feet of a tribut o urface drinking water supply _ the system is located in a ni en sensitive area (Inte ellhead Protection Area - IWPA) or a mapped Zone II of a public wa supply well If you have an ' es" to any question in Section E the system is consider'anye ificant threat, or answered "yes" in Sectio above the large system has failed. The owner or operator of system considered a significa eat under Section I3 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. ' Title 5 Inspection Form 6/15/2000 4 6 Page 5 of 11 r OFFICIAL INSPECTION FORM - NOT FOR VOLXJNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Proper h' Address: 'i Equestrian estrian 9 Drive North Andover, MA . Owner: Vincent H If ' h e ric Date of Inspection: 8/21/00 Check if the following have been done. You must indicate "yes" or "no" as to each of theifollowing: 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 inspectiort ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) V _ Was the facility or dwelliiig inspected for signs ofsewage back up ? V _ Was the site inspected for signs of break out ? J _ 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: Yes ono � Existing information. For example, a plan at the Board of Health. ZDetennined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] I Title 5 Inspection Form 6/15/2000 5 t Page 6 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION Property Address: 1 Equestrian Drive North Andover, MA Owner: Vincent Helfrich Date of Inspection: 8/21/00 ✓ CONDYTIONS RESIDENTIAL Number of bedrooms (design): H Number of bedrooms (actual): _ VA DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 4 qO Number of current residents: _ Does residence have a garbage grinder (yes or no): NO Is laundry on a separate sewage system (yes or no): VO [if yes separate inspection required] Laundry system, inspected (yes or no): _ Seasonal use: (yes or no):, Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): JVQ Last date of occupancy: r j ; 1,ch COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): < Grease trap present (yes or no): Industrial waste-holding tank present (yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Lasp date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: 2 iL YerA,5 rt G, a Was system pumped as part of the inspection (yes or no): be If yes, volume pumped:15-co gallons -- How was quantity pumped determined?' Reason forP� gurri m� P y�i�'�z Q•EG�.�I=�,T 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) _ Tight tank _ Attach a copy of the DEP approval _ Other (describe): Approximate age of all components, date installed (if known) and source of information: (c-> 1- 1?—deCA-S. Were sewage odors detected when arriving at the site (yes or no): il17 Title 5 Inspection Form 6/15/2000 6 t f t Page 7 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI6N FORM PART C f SYSTEM INFORMATION (continued) Property Address• I E questrian Drive North Andover, MA Owner: Vincent Helfrich Date of Inspection: 8/21/00 BUILDING SEWER (locate on site plan) Depth below grade: 3 Materials of construction: —%ILI—cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Nth Comments (on*condition of joints, venting, evidence of leakage, etc.): P t Pt: t -4 --ori, s n JA- t ti t>i fl SC^1 L Zvi SEPTIC TANK: _ (locate on site plan) Depth below grade:_36 Material of construction: v<'o-ncrete _metal _fiberglass _polyethylene _other(explain) If tank it metal list age: _ ,Is age confirmed by a Certificate of Compliance (yes or no): _ (Attach a copy of certificate) Dimensions: ISo:i is ASS Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3) , Scum thickness: 4-1 " r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 15,• How were dimensions determined: ML-.#qso 217- :5. -nC iA Comments (on pumping 'recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TR1v1k i N <r00 7 Co. V. c e-rY e. -1-r- A-.' C��.•i D i n U Al, %ZC o M — D TR G'" l ti -S L i -.9-n ^ Al ` t= 2 1 S C/t S Cc't/L �w C�/��-via; � s n% w , � }•{�.v �-" u/= �i.v s/� G-2�l"C�C GREASE TRAP: (locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass_polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: T Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Title 5 Inspection Form 6/15/2000 7 k7 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION (continued) Property Address: 1 Equestrian Drive ; North Andover,: MA Owner: Vincent Helfrich Date of Inspection: 8/21/00 i SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: XLP, Pc 12 /Ts t3ud t-71 overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, 'signs of hydraulic failure, level of ponding, damp soul, condition of vegetation, etc.): CESSPOOLS: UA (cesspool must be pumped as part ofiinspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: . Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: �& (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' SYSTEM INFORMATI6N (continued) Property Address: 1 Equestrian Drive North Andover, MA Owner: Vincent Helfrich s i Date of Inspection: 8/21/00 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Equestrian Drive North Andover, MA Owner: Vincent Helfrich Date of Inspection: 8/21/00 SITE EXAM Slope Surface water Check cellar vi 5-0—PI nj-2�) Shallow wells �,;,Al Estimated depth to ground water & feet 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) 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: � ► l % FI L1,eq reA-f` - iA(Z 1_40 ()z 11-104'., V5S S n.�R�i�.y w 4rL2 7 c�c (o_ 'z'(5 n.�R�i�.y�w 4TL2 7%c�c (o_ '� G--2u �.n S✓Q FRCS. Title 5 Inspection Form 6/15/2000 11 �--V V�s3 AlV164a(7�j 217 (a4Rp OP ER soppul L -or Z % L,4c0N14 'ewe D wEc c_ W"PRE SS St�T"1G Sy STEc� �IC� -- — bPP�{ovt^v DArt' APR�VIAJ6 Aun-toJ';�IrY J DI�PPx�v� Co�o�t�o�s io DwL 11 � - C- x4V4T(o, J )NSPt�-6-po,\j '5 PT'c c S\iSTCM 1 J STA U-.4TIoAJ 94rc Q S [] FAIL WSPE�:TIonj PIPE FROM Ham ry TAO r [:1 Pry S5 � I=IO1L- 4PPRd\)E GpTC,-2,L —r� APj21g7vjn)G A�T+t01�►Ty �� I NS T4 bLc- &PITg0PAL, IA)5%bzi 10nj5 ���= A►-�y) r l a��r ,`' ►vu� i DISAPPI?OvF,D DA _ j`G 14 Lt 7 rC R�O�o NS FML APPN)V4L D,o�E��'�� � APP13WVJ6 /6u i HoRI i�,/ C��/ 1 BOAKD.0F HEALTH7� No.Andover, Mass. �� SUBSURFACE DISPOSAL DESIGN CBMK LIST tir LOT 7CN(d CI ii APPROVED DATE DISAPPROVED DATE Provided: Reasons: Title V FAIL Og Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions mot #,abutters b location and location and resultsppercollationnt tests-aistanceeto ties to s c red leaching area d design calculations & calculations showing required (e) location and dimensions of system -including reserve area f) existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal ur system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer-Planning Board files (j) known sources of water supply within 2001 of sewage disposal a system or di.sclainer (k) location of any proposed well to ser v lot-1001 from leaching facilit (1) location of water lines on property-'.01 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction tic tank (4) Profile of system-elevations of I .se..ent, plumb, pipe., s eP , distribution box inlets and outl.,cs, distribution field piping and etker elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6 Septic Tanks (a) capacatias-150% of flow, water table, tees, depth of tees, access, pumping 1(b) cleanout (c) 10+ from cellar w,*11 or inground swimmi-ng pool (d) 25+ from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater 0.08 r �� Reg 10.41 (b) sump