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HomeMy WebLinkAboutMiscellaneous - 10 COLONIAL AVENUE 4/30/201828 o 00 O W r 0 O O z_ N D gD m o z m bm e 1 ` MAP # LOT t PARCEL # STREETCC) �Y CQNSTRUCTI_QN-APP HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE /Z Ag - APP. BY_� T- DESIGNER: A4 PLAN DATE. CONDITIONS WATER SUPPLY: �WN WELL WELL PERMITDRILLER__----------._._....__.._....._.__..._......... WELL TESTS: CHEMICAL DALE APPRUVED BACTERIA I BACTERIA II COMMENTS: UA I E f1PPRUVEU DATE APPFtUVEll FORM U APPROVAL: APPROVAL TO ISSUE" �ES NO DATE ISSUED /Z 1� BY - _ ...._L�t/ ._ ............._.....-- CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER �1 ANY VARIANCE NEEDED To 110 FINAL BOARD OF HEALTH APPROVAL: YES NO YES NU YES NO YES NO "� 4 � NO DAZE: ........_ . _ ...BY: s' �f _ ' • ,7 r ���..G�Y�I�M�.NS.Ifl44,Hu QN - . ;.r ?!c' '-,,:,IS 'THE' INSTALLER LICENSED? + `; ++ „ r 1-�' 4 .� .s>:.; �.. ..,' .:ice": � �.:. i t .. �, i �3/' ••• TYPE.OF CONSTRUCTION: �? t REPAIR' .a . z- NEW CONSTRUCTION: CERTIFIED PLOT 'PLAN `REVIEW �YESNO CONDITIONS OF.. APPROVAL YES NO (FROM FORM U) s- ` ISSUANCE OF DWC PERMIT ` S NO ,' rDWC PERMIT NO. t INSTALLER:h''� BEGIN INSPECTION YES N0: t `. ..:,EXCAVATION.INSPECTION: :NEEDED: .. PASSED ^...:n. J: BY ' � °-CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: • APPROVAL TO BACKFILL: DATE: Com/ �� BY FINAL.GRADING APPROVAL: DATE lZ 4 BY FINAL CDNSTRUCTION APPROVAL: DATE: BY 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. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System l=oan - Not for Voluntary Assess CO- LU 'I iq- hvc Prd"perty Address 0 l( Owner's City/Town r2A dtsgs� It -13 -() State Zip Code Date of inspection Inspection results must be submitted on this form. inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector. Name of Ins pctor _ .� G 4 o an Name a /3 2 - dress dress 'City/Town i 7k �4 23 07 6 Telephone Number B. Certification � 16211 N� OR�N PN�N FZ 1!11A CI /6 State Zip Code si;2J �L� Ucense Number 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 X��& (/ Y --�� -Inspectofs igna ure 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. tSns • 31;3 Title 5 Officia+ inspection Form: Subsurface Sewage Disposal System • page 1 of 17 Commonwealth of Massachusetts t9, Title 5 Official inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's a information is required for every page. CitylTown 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: /UU ' A -e I `, l�' ! N 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. box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not lr',piease explain. The septic tank is I and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits subsI infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank placed with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection i s structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less t an2 years old is available. ❑ Y ❑ N ❑ ND (Explain below). tSins • 3/13 Title 5 Official Inspection Form. Supsufface Sewage Disposal System • page 2 of 17 Commonwealth of Massachusetts `- Title a Official Inspection Form Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Owner information is required for every page. Property Address --'—' -- cc Owner's Nam City/Town B. Certification (cont.) State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Prgzss/alarms are repaired. B) System Passes (cont.): ❑ Observation of sews ackup or break out or high static water level in the distribution box due to broken or obstructed pi or due to a broken, settled or uneven distribution box. System will pass inspection if (with approva Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ ❑ N ❑ ND (Explain below): El distribution box is leveled or replaced ❑ Y ❑ 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"We Board of Health: ❑ Conditions exist which require further evalu on by the Board of Health in order to determine if the system is failing to protect public health, sa or the environment. I. System will pass unless Board of Health Bete 'nes in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in am ner 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 we land or a salt marsh t5ins - 3/is TWe 5 Of dal Inspection Form; Subsurface Sewage Disposal System • Page 3 of 17 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, s-afety and environment: ❑ Th—e-systpm has a septic tank and soil absorption system {SAS} and the SAS is within 100 feet of a su water supply or tributary to a surface water supply. ❑ The system has a sep ' nk and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an�Sd supply well. ❑ The system has a septic tank and SAS and the more from a private water supply well". Method used to determine distance: the SAS is within 50 feet of a private water than 100 feet but 50 feet or ** This system passes if the well water analysis, performed at a DEP certified l4twratory, for feral coliform bacteria indicates absent and the presence of ammonia nitrogen and nitraftS nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of 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 ❑V109 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 1/2 day flow 15ins • 3113 Title 5 OffieW inspedion 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 Avg— Property Address Ccs � I l owner information is Owner's N a ` required for everyVeA page. 7,�; Cityfrown 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, s-afety and environment: ❑ Th—e-systpm has a septic tank and soil absorption system {SAS} and the SAS is within 100 feet of a su water supply or tributary to a surface water supply. ❑ The system has a sep ' nk and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an�Sd supply well. ❑ The system has a septic tank and SAS and the more from a private water supply well". Method used to determine distance: the SAS is within 50 feet of a private water than 100 feet but 50 feet or ** This system passes if the well water analysis, performed at a DEP certified l4twratory, for feral coliform bacteria indicates absent and the presence of ammonia nitrogen and nitraftS nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of 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 ❑V109 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 1/2 day flow 15ins • 3113 Title 5 OffieW inspedion Form Subsurface Sewage Disposal System • Page 4 of 17 Owner information is required for every page. t5ins - 313 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments d C'6/ Property Address Owner's Name City/Town " - B. Certification (cont.) Yes No Ott' -(-S, 111-17--1 i state Zip Code Date of Inspection ❑ 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- 1 0,000g pd. ❑ 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 questi in Section D. Yes ❑ ❑ the system is within 400 feet surface drinking water supply ❑ ❑ the stem is within 200 feet of a trib to a surface drinking water supply El 0the syste is located in a nitrogen sensitive ea {interim Wellhead Protection Area — IWP ora mapped Zone II of a public w r supply well If you have answered "yes" to any ques ' n in Section E the system is cons a significant threat, or answered "yes" in Section D above the ge system has failed. The owner or operator of any large system considered a significant threat underction E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. Thystem owner should contact the appropriate regional office of the Department. Title 5 offi&st_ inspection Form- Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments /a 6'1U Property Address �� 1 Owner Owner's l information is required for every page. Cityfrown .Sf tatep� Date of inspection C. Checklist Check if the following have been done. You must indicate °yes" or "no" as to each of the following: Yes No M❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ �j 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) 1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 4fycj t5ins • 3113 Tide 5 Official inspection Form: Subsurface Sewage Disposal System • Page 6 of V Commonwealth of Massachusetts =.' t Title 5 official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address r, , Owner information is required for every page. tSins , 3113 L1 Uw ners -Ano Z �' e,� � 404'1(5` U-13-12 Citylrown State Zip Code Date of Inspection D. System information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type Establishment: Design flow ( d on 310 CMR 15.203): Basis of design flow (sea ersons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Wal-- meter readings, if available: per day (gpd) 1W ❑ Yes No ❑ Yes No ❑ Yes No ❑ Yes ( No -1n-- ❑ Yes j No w - Date P Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No idle 5 Offiwi inspection Form; Subsurface Sewage Dispose: Sysier, • Rage 7 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address � t Owner" information ie O;"` e r ame 4 Q f� / ^ ( 2 required for every >/�. 1 1 page. City, own State Zip Code Date of inspection D. System information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: --390e 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: ---N gallons Date (� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Yes{ No ❑ Privy Shared system (yes no) yes, attach previous inspection records, if any) ❑ Innovative/Aitemative 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): 15ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 officialInspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Owner's /-I C lc� ( ISIQ � e-1 4(,'C_ G1 ta5 to Zip Code bite of inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: mak& nz-. Were sewage odors detected when arriving at the site? Building Sewer (locate on site pian): Depth below grade: Material of construction: Acast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: ❑ Yes �No l__k___ feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): & S Septic Tank (locate on site plan) Depth below grade: Material of construction: PQ concrete ❑ metal ❑ fiberglass If tank is metal, list age: feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: xl V Sludge depth: a,l t5ins • 3113 Title 5 Official Inspection Form: Subsurfax Sewage Disposal System •Page 9 of I-/ Commonwealth of Massachusetts a °' Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Namr-., information is requied for every t "L � � • r i�c � 1l—� page'. City/Town State zip Code Date of Inspection D. System Information (cont.) r Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle u Scum thickness Distance from top of scum to top of outlet tee or baffle k Distance from bottom of scum to bottom of outlet tee or baffle 42 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.): C�1-7 2e-5 I n c Grease Trap (locate on site plan): Depth below Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness fiberglass 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: t5tns • 3113 fleet ` ❑ polyethylene ❑ other (explain): Date TWO 5 Official Inspection Form: Subsurface Sewage Disposal System • page 10 of 17 t ' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address _ OwnerOwner's owners Nam�information is " B crequired for every % c � 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 Depth below grade: Material of construction: of inspection) (locate on site plan): ❑ concrete [I metal ❑ fiberglass Q Capacity: -'- Design Flow: Alarm present Alarm level: Date of last pumping: Comments (condition of alarm and float switches, gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date ❑ other (explain): ❑ Yes ❑ No Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/133 Tiff° 5 Official 6-tspection Foran: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Foran . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address — ---- Owner Owner's N me information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site pian): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): .) ( tne--t �-j/ -z-/ —I rump tonamner (locate on site plan): Pumps in working order ❑ Yes ❑ Noy` Alarms in working orderer ❑ Yes 0 No' Z ►ments (note condifion of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system Soil Absorption System (SAS) (locate on site plan, If SAS not located, explain why: conditional pass. required): t5ins • W13 Title 5 Otfiaal lnspecUen 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 Property Address Owner information is required for every page. State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches Xleaching fields ❑ overflow cesspool number. number number: number, length: number, dimensions: 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth of liquid to inlet invert Depth of solids Jaye Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3113 TWe 5 Off tial inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments OU j �-f 14-tk.L_ Property Address G l �' uwners� NaMgI--> City/Town State Zip Code Date of Inspection D. System Information (cont.) CoTments (note condition of soil, signs of hydraulic failure, levef of ponding, condition of vegetation, etc.) Privy (locate on site plan): Materials of construction: Dimensions Depth of solids tStns - 3113 Tale 5 official Inspection Form; Subsurface Sewage Disposal, System • Page 14 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 Property Address t ( I -- vwrrcm s jut$ 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 t5m` - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Tine 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property L W Owners Name - City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water /U�cs� ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 5`f% feet V Please indicate all methods used to determine the high ground water elevation: 0 C W Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting prop"lobservation 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; Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins •3113 Title 5 Oftel fnsPaMon Forth: Subsurface Sewage O40" system - Page 16 d 17 a Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 l Property Address Owner Owner's information is required for every S"�—� page. itydTown 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 - 3113 Title 5 Official tnspecfion Form: Subsurface Sewage Disposal System • Page 17 of 17 U Town of North Andover HEALTH DEPARTMENT CHECK#: DATE: 11-16- 0/'7 LOCATION: /0 C/-01-/-O/)/'CLI/ Z��c I/ H/O NAME: r-, / / CONTRACTOR NAME: &Iclteu TyRe of Permit or License: (Check box) 0 Animal $ • Body Art Establishment $ • 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 $ • Trash/Solid Waste Hauler $- • Well Construction $ SEPTIC Systems: • Septic - Soil Testing $ • Septic - Design Approval $ 0 Septic Disposal Works Construction (DWQ 0 Septic Disposal Works Installers (DW[) 0 Title 5 Inspector $ xTitle 5 Report PC,55 $5-0- 11 Other (Indicate) $ &�I'--D HealtkAgent Initials White - Applicant Yellow - Health Pink - Treasurer 4. T Q. i^ COMMONITALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - ' DEPARTMENT OF EwiRoNMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretan ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION r Property Address:l� / / Lj a/�. Name of Owner C S Address of Owner: Date of Inspection ]✓ Name of Inspector: (Please Pnirt) 0, 0.� am a DEP pproved system insI; or pu s�C to Sec cm 15.340 of Title 5 (310 CMR 15.000) Company Name:�- Mailing Address: Telephone Number: CERTIFICATION STATEMENT I certify that 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: —Y Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS T revised 9/2/98 Pap.I of II 0 Vf -ted — Recyc ird Paper G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION�(%ct'o�ntinueDd) 'roperty Address:��o /f' Owner: fr I N e S Date of Inspection: 7--11 _ INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: ` r 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Co /- D N / q L tll . Ia // 110o d c Owner: Date of Inspection: 7-1/- aoo d C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less then 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII e -y M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /0 p L d /i / l L- dC �l. /)J u v Owner: Date of Inspection: i �L C 7 -�l - �o o fl D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility- or system component due to an 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 112 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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 then 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: - The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /t O iv / 1 ,q�`" Owner: 04I S Date of Inspection: 7- 1/- o o o Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes `.l- No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the Interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)l The facility owner land occupants, if different from owner) were provided with information on the proper maintanaacs of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Co/ SYSTEM INFORMATION ,Fop" Address- /0 C�o o r %f L 1 %l1 �J ,�/t% y c Owner: / Date of Inspection:&g. // S 7' l / O D O FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedr o Number of bedrooms (design): Number of bedrooms (actual):_ Total DESIGN flow C Number of current residents: �� Garbage grinder (yes or no):Wo Laundry (separate system) (yes or no/ U: If yes, separate inspection required Laundry system inspected (yes no) Seasonal use (yes or no): --,f 71, Water meter readings, if available (last two year's usage Igpol: Sump Pump (yes or no):--L%C/ Last date of occupancy: COMMERCIAL/INDUSTRIAL: r Type of establishment: Design flow: gpd ( BAe8 015.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: I/�1' j` v System pumped as part of inspection: (yes or no) f' S If yes, volume pumped: 0 0 gallons r Reason for pumping: TYPE OE SYSTEM L,1' 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) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of'DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)�� r revised 9/2/98 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address:Q (30 �•. D l✓ / �? %)"'� /� U d�Er' +r Owner: Date of Inspection. 1i f BUILDING SEWER: (Locate on site plan) Depth below grade:') Material of construction: _ cast iron '40 PVC _ other (explain) Distance fromprivyl water supply well or suction line Diameter� /� Commentss- (c6ndition of joints, venting, evidence of leakage, -etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: LI -Concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge dept Distance from top of sludge to bottom of outlet tee or baffle:----/ 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 baffler_ How dimensions were determined: 19,44 S r T 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) �c-�-r a 1,2 (a i1 .Ji fires-� GREASE TRAP: r (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 lest pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7oru W e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Iroperty Address: / �a Owner 6 N r L, ��� /'/i j �, ✓ C ' \ r /// I / ► Date of Inspection. --'(t G S TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes — No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:Y� S (locate on site plan) 777777������ / Depth of liquid level above outlet invert: / f1�Jj / Comments: (note if level and distribution is equal, evidence of solids carryover, evidence —of leakage into or out of box, etc.) PUMP CHAMBER:_! J' (locate on site plan) /! Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) `roperty Address: n Jwner: ^� Date of Inspection? SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technqlogy: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) O F '!,!J/ f C/ Lf C //-6/,L CESSPOOLS: _ (locate on site plan) Number and configuration: ' I' Depth -top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) dMaterials of constructio Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Nop" Address: /,o �� L p Ai / v G• / y eD D V t k lune.: G Q , /Y L S Date of Inspection: �! SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t } revised 9/2/98 Page 10 of II Is i 9-0 e y s ! P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 PART C / SYSTEM INFORMATION (continued) operty Address: 0 D l— D %✓ / L // 1/� r r r !f f�� i7 'r 1 !�'I � t .Jwner: Date of Inspecti . A / if C i NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Ce water C+e4 6V41" Shallow wells Estimated Depth to Groundwater i Feet t I Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) f,- t>G f� /� C�i /v'/ ) it It,, A & 1- 5• revised 9/2/98 PagcltofII Commonwealth of Massachusetts City/Town 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 1. System Location: Left / Right front of house, Left / Right rear of house, Left nght side of hou , Left / Right side of building, Left / Right front of building, Left / Right rear of building, n e Address �0__..�� w City/Town c�(L) State Zip Code 2. System Owner. Name Address Cd different from location) Citylrown ' B. Pumping 1. Date of Pumping 3. Type of system: Stat Telephone Number RECEIVED r` AJI u � � � � JUL 13� . 2015 Date' 2. Quanti �� RTH ANDOVM HEALTH DEPARTMENT Mons , ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yap If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of System: 6: System Pumped By.- Nell. y: Neil. Bateson Name Bateson Enterprises Inc- Company ncCompany 7. Location wherpe contents -were disposed: C�.L`S.j,1_ _ Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc- 06103 1 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of No.Andover' } ° System Pumping Record riAR -U 2012 ,M Form 4 TOVIN OF NORTH ANDOVER F __L EEA TH DEPARTMENT i 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. 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. reNm 1. System Location: Address No.Andover Ma 01886 City/Town State Zip Code 2. System Owner: e ;1 Name CL Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 7?� 1. Date of Pumping D e 2. Quantity Pumped: allons – — ZO 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: o(m u stem Pumped By: C ame Vehicle License Number Stewart's Septic Service Company nst,wart's ation where contents were disposed: Pre -treat nt Plant, 20 So. Mill Bradford, Ma 01835 nature Signature of Date Date 1� t5forrn4.doc• 03/06 System Pumping Record • Page 1 of 1 6C 'i 0 Town of North Andover HEALTH DEPARTMIEN "SACmU CHECK #: D TE LOCATION: H/ 0 NAME:k z�� , C 0 N T R A C T 0 R N A M E: �, lw�1,111,1-wlll' Type 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 $ • Swimming Pool $ • Tobacco $ • Trash/Solid Waste Hauler $- • Well Construction $ SEPTIC Sustems: • Septic - Soil Testing $ • Septic - Design Approval $ 0 Septic Disposal Works Construction (DWQ $- 0 Septic Disposal Works Installers (DWI) $ 0 Ti 5 Inspector $ -31 E Title &� zitle 5 Report $ �51 I 11 Other (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer J & S DEVELOPMENT CORPORATI -- " I North Andover board of health I 02/16/12 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 10500 50.00 Haverhill Bank 9613 titIe5 10 Colonial ave 50.00 ' Commonwealth of Massachusetts ©g t --L,- Title Title 5 Official Inspection Form �c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address — - Noelle Schofield Owner Owner's Name information is No.Andover Ma 01845 2/20/2012 required for _ _ every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. /rab rerom A. General Information 1. Inspector: John DiVincenzo r- rl F Ed ; 2 2012 v V LR Name of Inspector HEALTH DEPARTMENT Stewart Septic Service _ Company Name 58 South Kimball Company Address Bradford Ma 01835 City/Town 978-372-7471 Telephone Number B. Certification State Zip Code S113386 License Number 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 2/20/2012 In p ctor's Signature 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. l5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachbsetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address Noelle Schofield Owner's Name No.Andover _ Ma City/Town State B. Certification (cont.) 01845 2/20/2012_ _ Zip Code Date of Inspection 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 t5ins • 11/10 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1n (:nlnnial AvP Property Address Noelle Schofield Owner's Name No.Andover Ma _ 01845 2/20/2012 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 l5ins - 11/10 Owner information is required for every page. t5ins - 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address Noelle Schofield Owner's Name _No.Andover Ma 01845 2/20/2012 — City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance:-- ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 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. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form a _ — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '( 10 Colonial Ave — — Property Address Noelle Schofield Owner information is Owner's Name No.Andover Ma 01845 2/20/2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or ❑ obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area – IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form Not for Voluntary Assessments -_ 10 Colonial Ave -- -- — ---- — Property Address Noelle Schofield — Owner Owner's Name information is No.Andover Ma 01845 2/20/2012 required for State Zip Code Date of Inspection every page. City/Town C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 4 . Number of bedrooms (design): 4 — Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 l5ins - 11/10 Commonwealth of Massachusetts -- -- : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address Noelle Schofield — Owner Owner's Name information is No.Andover Ma _ 01845 2/20/2012 required for every page. CitvlTown D. System Information Description: State Zip Code Date of Inspection 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) ❑ 3 ❑ Number of current residents: ❑ Yes 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Water Meter readings - — — Sump pump? ❑ Yes ® No Occupied _ Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): 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 ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 l5ins - 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . " 10 Colonial Ave Last date of occupancy/use: Other (describe below): 01845 2/20/2012 Zip Code Date of Inspection Date General Information Pumping Records: Source of information: Andover Septic Was system pumped as part of the inspection? ® Yes ❑ No 1500 If yes, volume pumped: gallons Site How was quantity pumped determined? guage on truck, As built — Inspect Tank Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 t5ins • 11/10 Property Address Noelle Schofield Owner Owner's Name information is No.Andovef Ma required for Cityrrown State every page. D. System Information (cont.) Last date of occupancy/use: Other (describe below): 01845 2/20/2012 Zip Code Date of Inspection Date General Information Pumping Records: Source of information: Andover Septic Was system pumped as part of the inspection? ® Yes ❑ No 1500 If yes, volume pumped: gallons Site How was quantity pumped determined? guage on truck, As built — Inspect Tank Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 t5ins • 11/10 Commonwealth of Massachusetts - -� Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave — -- Property Address Noelle Schofield --- _— — Owner Owner's Name information is No.Andover Ma 01845 2/20/2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 16 Years Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 26" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): City Water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No B.T.G Manhole feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 l5ins - 11/10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address Noelle Schofield _ Owner Owner's Name information is No.Andover Ma 01845 2/20/2012 _ required for — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 28" Distance from top of sludge to bottom of outlet tee or baffle 28 — 1" Scum thickness-- Distance from top of scum to top of outlet tee or baffle -- — 14" Distance from bottom of scum to bottom of outlet tee or baffle — �- Tape measure ,_sluge judge 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.): inlet and outlet tees in good shape, no leakage, liquid levels good. 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 feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 t5ins • 11110 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments A, 10 Colonial Ave - Property Address Noelle Schofield -- -- — - Owner Owner's Name information is No.Andover Ma 01845 2/20/2012 _ required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: -- - Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 l5ins - 11/10 Commonwealth of Massachusetts -- s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Colonial Ave Owner information is required for every page. l5ins • 11/10 Property Address Noelle Schofield Owner's Name No.Andover Citv/Town Ma 01845_ State Zip Code 2/20/2012 _ Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0 Depth of liquid level above outlet invert — -- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Little solids carryover, pumped box, box is level, no leakage around box 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: Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth - top of liquid to inlet invert -- Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 t5ins • 11/10 Commonwealth of Massachusetts to Title 5 Official Inspection Form - - - o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave ---- ---- — -- - ---- Property Address Noelle Schofield — - -- Owner information is Owner's Name No.Andover Ma 01845 2/20/2012_ required for — State City/Town Zip Code Date of Inspection every page. D. System Information (cont.) Type: ❑ leaching pits number: - — - - ❑ leaching chambers number: - -- ❑ leaching galleries number: -- -- 4-1104 sq ft ® leaching trenches number, length: - ❑ leaching fields number, dimensions: - - - ❑ overflow cesspool number: --- - - ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hyo failure, noop nding, no damp soils Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth - top of liquid to inlet invert -- Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 t5ins • 11/10 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address Noelle Schofield ____ __ Owner Owner's Name information is No.Andover _Ma 01845 2/20/2012 required for State Zi Code Date of Inspection avPry Haas_ Clty/TDwn p _ p 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.): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 15ins • 11/10 0 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave — - Property Address Noelle Schofield --- Owner's Name No.Andover _ Ma 01845 2/20/2012 _ City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below IRI drawina attached separately Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 t5ins • 11110 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address _Noelle Schofield Owner Owner's Name - - !-- ----- - - ------ — - — information is required for No.Andover- Ma 0184_5 2/20/2_012 ---- --- -- --- — — --- - --- --- - ---- - - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 4 Estimated depth to high ground water: -— - 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: May 1995 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Owner had plans and as built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Taken from design plans on record. Hayes engineering wakefield ma May 25,1995 Revised Oct.3,1995, as built June 25,1996 Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts x Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Colonial Ave Property Address Noelle_ Schofield Owner Owner's Name information is No Andover Ma 01845 2/20/2012 required for every page.Date of Inspection City/Town State Zip Code E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 t5ins • 11/10 TJ 22 g s I 0 BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 December 1, 1995 Mr. Peter Ogren 603 Salem Street Wakefield, MA01880 Re: Lot #1 Colonial Ave. Dear Mr. Ogren: TEL. 682-6483 Ext23 This is to confirm that the North Andover Board of Health granted a variance to North Andover Regulation 2.14 to allow a design rate of 110 gpd instead of 165 gpd for Lot #1 colonial Ave. If you have any questions, please call the office at 688-9540. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp cc: AC Builders File FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section************QQ****** APPLICANT: ��• W��N1 - Phone 4D��v TO LOCATION: Assessor's Map Number Parcel Subdivision 11V061*4 5 Lot(s) Street (.. A6Ak;'+/ rI�►T _ c+. 14 --lb ************************Official Use Only************************ RECOMMENDA IO S F GENTS : e�+ eit-,zDate Approved Conservation Administrator �1 Date Rejected Comments Z� b, �� (=j i g C Date Approved C Town Planner Date Rejected Y Comments E7-C:n ,1:�� n Date Approved Food Inspector -Health Date Rejected Date Approved Septic Inspector -Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department p� /%� R�cei ed by Building Inspector Date PLAN OF LANG /N NO. ANDOVER, MASS. SCALE- I* = 40' MAY 21, 1996 HAYES ENG/NEER/NG, INC. tN/AZZ 603 SALEM STREET C/V/L ENGINEERS & WAKEF/ELD, MASS. 01880 LAND SURVEYORS M. (617) 246-2800 / CERTIFY THAT THIS FOUNa477ON /S LOCATED ON THE GROUND AS SHOWN, AND TAAr /T CONFORMS TO THE ZONING BY-LAWS OF THE TOWN OF NORTH ANDOVER. / FURTHER CERT/FY THAT THIS PROPERTY DOES NOT LIE W/TH/N A ROOD hAZARD AREA (ZONE A OR V� AS SHOWN ON FLOOD /NSUAAMCE R47E AMP COMMON/TY PANEL NUMBER 250098 000106. EFFECTIVE DATE.• ✓UNE 15, 1983 DATE: MAY u P. R. D. (R-2) V R. M/N/MUM SETBACKS.• FRONT = 20' SIDE = 20' (SEE SEC. 8.5.6. D.1) REAR = 20' PROFESS/0 1�1N0 NN UrRO Of Hr-„• 30A W o Z O Z = J E a p- 8 W O LL -% JI LU -C Cr 0 J N a W :J U. Z O K U c a 3 — m ci W Z z � a a z LY b O ` a LA ro F- U p > U J `^ C' Q Ln OC !1 LLJ > 2 O O Q O -v u- z a-�Iy r c O a -- Q a o Q � tA z m O o r. c c J c Q _ 0 �° O ) tA Y b ro w� E ul tA cu i n a Z a� — � ro 0 a 1 a ro O r o= ro o N e y dC ro e f1. a) 3 N o�M°1 .w� �' Q in d Ln Li HAYES ENGINEERING, INC. 603 SALEM STREET WAKEFIELD, MA 01880 (617) 246-2800 FAX (617) 246-7596 October 3, 1995 Mr. Richard A. Colantuoni Building Inspector Town Hall 146 Main Street North Andover, MA 01845 RE: Woodland Estates - Test Hole Information Dear Mr. Colantuoni: REFER TO FILE # NOA-0042 In accordance with our discussions back a couple of months ago, I have conducted the required test holes and inspected the soils on Lots 1, 2, 4, 5 and 6 Colonial Avenue in the Woodland Estates subdivision in North Andover. The procedure used was to excavate a test hole at each end of the proposed dwelling, determine the type of soil, and also estimate the seasonal high groundwater based on soil mottling. In addition, a comparison was made to the highest groundwater elevation of any nearby test hole conducted for the purposes of septic system design. Based on the highest groundwater encountered in the area, I recommended a cellar floor elevation at least two feet above the highest elevation. My conclusion is that underdrains are not necessary under the Mass. Building Code on Lots 1, 2, 4, 5 and 6 Colonial Avenue. I trust this information is suitable for. your purpose, and, by means of this letter, am requesting you to notify Sandy Starr, Health Agent for the Town of North Andover, so that permits may issue on these lots. Ve truly yours, %$ OF Of �c (� yG �J �1 J. y WREN Peter J. Ogren, P.E., 033604 President sua PJO/dab Enclosure cc: A.C. Builders, Inc. LO CY) O N L W O �i U) r W Z O CO = LIJ U Q Cf) O W Q LL zo zw LLIw Q W mop un W 3r Q H Q' O z c ,o � d T o o O o 0 m Z z Z Z Z C d1 .a N tf) O tf) O U') 0 > N M to T Ili O W tr) LO L a -a m E c 7 d E E M 00 to N CA to 00 d 'c Ew T T O 0 d Q' C* 0 tO T rn co N d = to tci C) M OO d C N ce) Cf) F- 2 N (flC O rn n OCw O C C O O = O M Z Z M z Z U) E T W v ELS 00, O d 0 dw r�M 31- otn tno 9 t Co O L M M LO M M M M M NV _ T T- 0 0 N wT CL otiM LO t- Oto to to C) U') 4� �qq >_ ITsi' ItNt' tLO0 W0 d 0) O N 0 0 N co �-- > >> > > 0) 0) cm/coo w cm Im /civ /two /trot (m V/ v/ v) Q CO VJ O .-... Z W- Qm = Nm �m to U') (0CD 0 N M V 11j O J a C: W t m u w w N M T1 r- ItORTh 16. 41 HUS Town of North Andover, Massachusetts ROARD OF HFALTH Form No.2 Qaz�:� /S" U DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant R Test No Site Location Reference Plans and Specs NGIN .TE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIRMAN, BOARD OF HEALTH Site System Permit No. -? q o - 4), V�- Az- V-1 t- v' �� I � I� j 'I I � I i'I � lo, 0 77V;�Pz-.ii, AJ 7- �*7 I _ .. �._ _�. �. __.r.... �_...-.__ _�. -._ �'';� c L, L,e 5 o(L 35 k,AjCXD r, -)_l --s-7k-f - s 'ER: MASSACH•USE77, f• X10.•! 9, z�,�,,�,a�1; �,F�"Y� '���;c`'',:;'': �..:..- - , .. DEP hs' Provlded Ihlivlolrn ro, Sao p al Boa Io the loch 8ca/c: cr �oalln pr cln, A, Faclllty In(orm��lon TOWN OF NOR _ HEALTH DEPARTMENT ,•a rl - "..p r,� •..'611 l/' �`Q^i �.. ,.; ;,; jir' '.�; SySlBm OWnor (114V(rrinl rcvn buVcn) Cq^o+.n -19�� . 11�9non1 n,mOr, — ,. 'UmPlu Regord ' "•� I'll, , � ,I:.lwlr';• 1.' 0919 Q!1Pvmpiq 3' Type 41 jyslam;.. (9) 1 i' 09997001 $0P0c Ten,, 7 9scrib9�: Ehlvonl 190 Flile('P(piQnt? [' Yv9 ,:1J1 ,.!• i.`•. ��:;�.i'.N,Ti,).(,'��r•i:'�jl��,r �Il�lr i99 n'8) I; :'62ne0? � YFS — "Co11dlyori'Q(:9yt,em;' '. 1, +;i���r Y;. tl' ��I '; 1'''I .• . 6,'. SY Qui• �m od 8 ':,' , ., ..';,•`. ��'llr'f� N�ii .1'4i) jai' t'/' 1,', ;,I v �� �'�'(.,�� r, v�q,�l,�1� 1,.1 ���•, 4a -01 �' ����p�l•'I'•I•, 111.. - .1.•.:, 1v�9r��oonlanla',yr9re diypos9v: • ....�' '•+ I' ;.1, �/tib'. \ ��'", masa.gor/d9plva(0i/ep�roYaJa/Ib/orms.r naln9v9cl VII)IC1i'UG4Aj "i Town of North Andover, Massachusetts BOARD OF HEALTH Form No.1 0;-*",-- jo, APPLICATION FOR SITE TESTING/INSPECTION Applican Site Location LnT -* I L )oo AL Laiv-t a �- c, Engineer NAME ADDRESS TELEPHONE Test/I nspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee ls—D-C-u Test No. 43 e' S.S. Permit No.—D.W.C. No.—C.C. Date—Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Form No.1 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/l nspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No S.S. Permit No.-D.W.C. No. C.C. Date-Plbg. Permit No. K , DATE" j. i ` t w� iww } c SYSTEM LOCATION (example: left front of house) f ; _ DATE .OF PUMPING: —/ 3 ©1 QUANTITY PUMPED lack GALLONS CESSPOOL:, NO YES SEPTIC TANK: NO YES 1 ' ` NATURE OF SERVICE:— ROUTINE. EMERGENCY ', i , , 'SERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER, OTHER (EXPLAIN) SYSTEM BUMPED BY: • Ca`v C'7O ENTS: , MIN i CON TE TS a ° 9 �., T, TRANSFERRED TO: L�l 1 % �� ��T-o CIJ AM 8 i F ii,f`+�`l•(rt���1i�sifl 7' P, . i�� 4.'-f k, t/////� I��t �nlvl Tv i SYSTEM OWNER & ADDRESS /0 � , q 1'Y "���t�,Y�rl {u �'�'��� L: !laji �;�4�ri�i l �.•r>.. }t , ,� rz": ri . SYSTEM LOCATION (example: left front of house) f ; _ DATE .OF PUMPING: —/ 3 ©1 QUANTITY PUMPED lack GALLONS CESSPOOL:, NO YES SEPTIC TANK: NO YES 1 ' ` NATURE OF SERVICE:— ROUTINE. EMERGENCY ', i , , 'SERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER, OTHER (EXPLAIN) SYSTEM BUMPED BY: • Ca`v C'7O ENTS: , MIN i CON TE TS a ° 9 �., T, TRANSFERRED TO: L�l 1 % �� ��T-o CIJ AM 8 i F ii,f`+�`l•(rt���1i�sifl 7' P, . i�� 4.'-f k, t/////� I��t �nlvl Tv i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE '1-.,21-6111' 01 a i cm V W NhK & AIJDRESS SYSTEM LOCATION DATE OF PUMPING_ I L I QUANTITY PUMPED _If L� Cl /OnS CESSPOOL NQ_Z YES NATURE OF SERVICE: ROUTINE V/ OBSERVATIONS: / GOOD CONDITION ✓ HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLID CARRYOVER SEPTIC TANK NO YES EMERGENCY FULL TO COVER BAFFLES IN LACE LEACHFIELD RUNBACK FLOODED OTHER EXPLAIN SYSTEM PUMPED BY COMMENTS: CONTENTS TRANSFERRED TO -- 4>