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HomeMy WebLinkAboutMiscellaneous - 10 DUNCAN DRIVE 4/30/2018North Andover Board of Assessors Public Access NO OTN of+.�■ •ANO • o� 4 # Swuo CHU+#�� Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial J Page 1 of 1 North Andover Board of Assessors Zmroperty Record Card Parcel ID :210/105.C-0005-0000.0 FY:2008 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO Location: 10 DUNCAN DRIVE Owner Name: BOURASSA, MARK & BARBARA Owner Address: 10 DUNCAN DRIVE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6 - 6 Land Area: 1.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2130 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 441,300 472,400 Building Value: 232,600 241,500 Land Value: 208,700 230,900 Market Land Value: 208,700 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1180794&town=NandoverPubAcc 11/7/2008 P, i 01 iu -loi f /I >o 00 IA P, iu -loi f /I >o 00 liv cNw 0 4 1 0 P, -loi f /I >o 00 liv P, -.1 °�A xrWYd 4<F�yat p r i r i r W O d d r r0 L ArC�Auty I H F d] O x . 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Cityrrown State Zip Code Date of Inspection 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 ❑QSignatbr Evaluation by the Local Approving Authority 11/11/2016 Ins 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 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.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 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 A. General Information filling out forms on the computer, Nov 1 )/1 1U1b use only the tab 1. Inspector: lV key to move your cursor - do not Neil Bateson TOWN OFNURINANOOVER use the return key. Name of Inspector Bateson Enterprises Inc. t19 Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI -15 Telephone Number License Number B. Certification 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 ❑QSignatbr Evaluation by the Local Approving Authority 11/11/2016 Ins 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 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.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Duncan Drive ,p Property Address Brett Rodden Owner information is required for every page. Owner's Name North Andover CitylTown B. Certification (cont.) t1A0 n1 ftdr; 11/11/2016 State 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): t5ins.doc • rev. 6116 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 10 Duncan Drive Property Address Brett Rodden Owner's Name North Andover MA 01845 11/11/2016 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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.doc • rev. 6/16 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 10 Duncan Drive Property Address Brett Rodden Owner's Name North Andover MA 01845 11/11/2016 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins.doc • rev. 6/16 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 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is required for every North Andover MA 01845 11/11/2016 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.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code C. Checklist 11/11/2016 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information Description: Number of current residents: 01845 11/11/2016 Zip Code Date of Inspection Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) No Industrial waste holding tank present? Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� On Well Water Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is North Andover MA 01845 required for every page. Cityrrown State Zip Code D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? Date 11/11/2016 Date of Inspection Pumped two years ago, owner If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Insoect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6116 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 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) RAA AAOAG 11/11/2016 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Tank & leach field 35 years old, 11/19/1981, as built plan. D -box was replaced 10/27/2008, info at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): 1.6 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast Iron through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 0.6 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) Dimensions: 10'x 5'x 4' Sludge depth: 5" ❑ Yes ❑ No t5ins.doc • rev. 6116 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 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is North Andover MA 01845 11/11/2016 required for 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 28" 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 14" 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.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic tank. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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.doc - rev. 6/16 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is required for every North Andover MA 01845 11/11/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6116 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 10 Duncan Drive Property Address Brett Rodden Owner's Name North Andover MA 01845 11/11/2016 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box was replaced in 2008, still in good shape. No carryover. No leakage. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc - rev. 6/16 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 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is North Andover required for every page. City(Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system RAA A A n A L 11/11/2016 Date of Inspection number: number: number: number, length: number, dimensions: number: 1 field 20' x 45' 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 (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.doc - rev. 6116 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 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is North Andover MA 01845 11/11/2016 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc • rev. 6/16 Title 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 10 Duncan Drive Property Address Brett Rodden Owner's Name North Andover MA 01845 11/11/2016 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 t5ins.doc - rev. 6/16 Title 5 Official 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 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is North Andover MA required for every page. Citylrown State D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells E t' +-.4 d th t h' h d t 01845 Zip Code 4 11/11/2016 Date of Inspection s rma a ep o ig groun wa er. 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: 5/19/1981 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. t5ins.doc • rev. 6116 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 10 Duncan Drive Property Address Brett Rodden Owner Owner's Name information is required for every North Andover MA 01845 11/11/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 : Commonwealth of Massachusetts — City/Town of . System Pumping. Record Form 4 DEP has provided this form for us&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 / Righ#front of House, Left /Right rear of house, Left / 1 h sided o h , Left I Right side of building, Left / Right front of building, Left / Right rear of building,Undereck . Address nn ���� L� V �_ ►v�� �V cityrrown State Zip Code 2. System Owner. Name' Address (d different from location) City/Town ' State a Zip Code Telephone Number `> s 1 i .B. Pumping R-ecord 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type -of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes q�'�"a if yes, was it cleaned? E]Yes [INo, 5. Condition of System: NOTA 6. System Pumped By. Neil. Bateson ' F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location • here contents -were disposed: Lowell Waste Water a --c 2) Date 0omt4.doa 06/03 1 System Pumping Record • Page 1 of 1 NORT" Of o, _ I 3? . 0 tj h • 9 Town of North Andover �,�'•�'-o ::,' HEALTH DEPARTMENT �SS�cHustt CHECK #: ATE: .' LOCATION: 1-1/0 NAME- ,6 ` CONTRACTOR AME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Report ' U:i tll 5e $ ❑ Other: (Indicate) $ n Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer A 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: 10 Duncan Drive 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall suba!itayofthisins ction re to the Approving Au ority (Board of Health or DEP) within 30 days of compl inspection. the syst 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. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic system. North Andover, MA 01845 RECEi Owner's Name: Marc & Barbara Bourassa d" Owner's Address: Same NOV 2 5 2008 Date of Inspection: 09-29-2008 V00. TOWN OF NORTH ANDOVER DEPARTMENT Name of Inspector: (please print) John Soucy Company Name: Soucy Sewer Service, Inc. Mailing Address: 78 North Broadway Salem, NH 03079 Telephone Number: 603-898-9339 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall suba!itayofthisins ction re to the Approving Au ority (Board of Health or DEP) within 30 days of compl inspection. the syst 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. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic system. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 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. 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 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(l)(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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. T 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: f Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS, cesspool or privy is below high ground water elevation. T Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No x _ Pumping information was provided by the owner, occupant, or Board of Health x Were any of the system components pumped out in the previous two weeks ? x _ Has the system received normal flows in the previous two week period ? x Have large volumes of water been introduced to the system recently or as part of this inspection ? x Were as built plans of the system obtained and examined? (If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up ? x _ Was the site inspected for signs of break out ? x _ Were all system components, excluding the SAS, located on site ? x_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? x_ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No x _ Existing information. For example, a plan at the Board of Health. x_ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder (yes or no): yes [recommend removal] Is laundry on a separate sewage system (yes or no): no [if yes separate inspection required] Laundry system inspected (yes or no): no Seasonal use: (yes or no): no Water meter readings, if available (last 2 years usage (gpd)): private well Sump pump (yes or no): yes Last date of occupancy: _current COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgtetc.): 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: Home Owner Was system pumped as part of the inspection (yes or no): yes_ If yes, volume pumped:150 gallons -- How was quantity pumped determined? Gage on truck Reason for pumping: Inspection and Maintenance. 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: 23 vears +/- Were sewage odors detected when arriving at the site (ves or no): No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 BUILDING SEWER (locate on site plan) Depth below grade: 32" Materials of construction: _cast iron X 40 PVC other (explain): _ Distance from private water supply well or suction line: 70' Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 4" 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'.5" x 6' Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 3 8" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Tae & Sludge Tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: _(locate on site plan) N/A 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.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other (explain): Dimensions: Capacity: - _ gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) N/A 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.): removed and replaced "D" box (permit attached) PUMP CHAMBER: N/A (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc) Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 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 trenches, number, length: X leaching fields, number, dimensions: 20'x45' 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 Sign of Hydraulic Failure. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) N/A Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: N/A (locate on site plan) N/A Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Duncan Drive North Andover, MA 01845 Owner's Name: Marc & Barbara Bourassa Date of Inspection: 09-29-2008 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. A 141w 411-�' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Property Address: Owner's Name: Date of Inspection: SITE EXAM Slope Surface water Check cellar x Shallow wells SYSTEM INFORMATION (continued) 10 Duncan Drive North Andover, MA 01845 Marc & Barbara Bourassa 09-29-2008 Estimated depth to ground water 6' _. 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: x Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Dug hole with auger in low drop off area. ' p4AtN Commonwealth of Massachusetts Map -Block -Lot 4, 105.0-0005- ----------------------- o a Board of Health Permit No North Andover BHP-2008-0215----------------------- P.I. HP-2008-0215P.I. rib•..'° ''��1 , FEE iss�cNustl F.I. � $125.00 � n ----------------------- Dispose '-� Permission is hereby granted L �� '� _------_----------------_-- to (Repair) an Individual Sewage Disf at No 10 DUNCAN DRIVE�•i-------------------- as shown on the application for Disp G� Q P �, ( y� �'�`� T' a S Dated October 27, 2008 ------------------------------ 117 ------------------------------------ I ssued On: Oct -27-2008 Board of Health by---Jggbn Soucy Cei TO CERTIFY, ] Boara v, . , _ North Andover \ e of Complia ce the In idual Sewage Disposal System at No 10 DUNCAN DRIVL'\ has been installed in accordance with theprovisionsof TITLE 5 of Sti application for Disposal Works Construction Permit No. _BHP -2008-021; Printed On: Oct -27 -2008 --------------------------------- Map -Block -Lot 105.C- 0005 - ----------------- Lnvironmental Code as descri Dated --- October 27, 2008 --- ---------------------------------------- Board of Health ----------------- in the Commonwealth of Massachusetts Map -Block -Lot 0 4 ,.•° •,*tido 105.C- 0005 - Board of Health ----------------------- Permit BHP -2008-0215 North Andover ----------------------- °+ P.I. FEE b, r� s SACNu4 t F I $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted John -Soucy ------------------------------ -------- ---- to (Repair) an Individual Sewage Disposal System. D- Z*x1 at No 10 DUNCAN DRIVE as shown on the application for Disposal Works Construction Permit No. BHP -2008-0215 Dated October -2-7,-2-008 Issued On: Oct -27-2008 Board of Health f WORT" Commonwealth of Massachusetts Map -Block -Lot °, •,•boa 105.C- 0005 - a p Board of Health -------------------- • North Andover b•-�,° �� Ce ific a of Complia ce ,SSAC MU TH S TO CERTIFY, hat the In idual Sewage Disposal System (R air) by ---J ......Souc--------------- ---------------- --------------------- --------------------------------------------- -------------------- -------------- Wler at No 10 DUNCAN DRIV has been installed in accordance with the provisions of TITLE 5 of State nvironmental Code as described in the application for Disposal Works Construction Permit No. BHP -2008-0215 Dated ---October 27,-2008 --- Printed On: Oct -27-2008 Board of Health of NORT : 1 FOj •a n , •- 09 • Town of North Andover HEALTH DEPARTMENT �s'4CHus°t CHECK #: ���� ATE:��,/O LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic -Design Approval $ Septic Disposal Works Construction (DWC) / $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ ealth Agent Initials White - Applicant Yellow - Health Pink - Treasurer of N4 ,y Applichtion for Septic Disposal System �? r6 �0Xonstruction Permit -TOWN OF ,r ORTH ANDOVER, MA 01845 ,SS^CNUSS /01;9-21dj�-j TODAY;t DATE $ 250.00 — Full Repair $125.00 - Components Important: Application is hereby made for a permit to: When filling out forms on the El Construct a new on-site sewage disposal system* se computer, u key E] it or replace an existing on-site sewage disposal system*only , ` to move your Repair or replace an existing system component — What? �0 " a cursor - do not key the return A. Facility Information Y 10 04,r, C 6 a2. Address or Lot # City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information f�)D(A Name Address (if different from above) City/Town State Zip Code i~ Telephone Rumber v/ 3. Installer Information -7-1tL 11 Qa 4cc ��c ct-G ,vl. Name _ w Name of Coripany Address City/Town State Zip Code Telep one Nu er (Cell Phone # if possible please) 4. Designer Inirmation Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 j VV Application for Septic Disposal System b`ST1..0 `pConstruction Permit -TOWN OF *' •A ORTH ANDOVER. MA 01845 PAGE 2OF2 A. Facility Informatio continued.... 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement T D 'S D TE $ 250.00 -Full Repair / $125.00 - Component✓ The undersigned agrees to ensure the construction and maintenance of the afore -described on-site age disposal system in accordance with the provisions of Title 5 of the Envir m ntal Code, as well as the Local Subsurface Disposal Regulations for the Town of No A over, and not to place the system in operation until a Certificate of Compliance has b en is ued by this Boar Health. Nanw Y Date Ap • •on A r&ed By: o d ,f Heal Representative) z j1 -6, Na ie ) Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Ssy tem? If so, Attach copv of Electrical Permit Yes No 4. Foundation As -Built. (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 4� SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: ►R (.'address of septic system) For plans by Relative to the application of G (Installer's name) And dated Dated 6 o ay s ate With revisior I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the a1212roved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept(a,townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer. I understand that I am solely resnonsihle for the installation of the svctem a, ner the me of this obligation. Undersigned Licensed Septic t TOWN OF NORTH ANDOVER Of AORTh � 3 Office of COMMUNITY DEVELOPMENT AND SERVICES o: •'��•� ^ '•�°°A HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director ®��� 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: /.q.�j,P/-/' LOT: INSTALLER: DESIGNER: �00�,:961 G� PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPEC IO . jp SITE CONDITIONS it ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 s TOWN OF NORTH ANDOVER a pORTp Office of COMMUNITY DEVELOPMENT AND SERVICES o HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 + ",. •i NORTH ANDOVER, MASSACHUSETTS 01845Ss4 "" � ACHUStt Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER t NORT1r Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 i 1600 OSGOOD STREET; Building 2-36 , ------- NORTH ANDOVER, MASSACHUSETTS 01845 �'Ss";C,,,;; t� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX D -BOX ❑ Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 °h" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel -less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation — Feb 2006 Page 3 of 6 ' TOWN OF NORTH ANDOVER M°RTh Office of COMMUNITY DEVELOPMENT AND SERVICES F p HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH. ANDOVER, MASSACHUSETTS 01845 �'SSACHUs t� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROLPANEL Comments: ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Wastewater System Documentation — Feb 2006 Page 4 of 6 TOWN OF NORTH ANDOVER t NORTN Office of COMMUNITY DEVELOPMENT AND SERVICES 10- - p HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, .REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 10' ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER pORTN 1 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �'Ss;;C U Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 CA 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 Addre: Owner's Name: Owner's Addres Date of Inspecth Name of Inspector• (please print) �V /T) Company Name: !SitVtor-*- �fJicL 5e U1Ce. Mailing Address: . 6183.5 Telephone Number: 130P 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 Fails Inspector's Signature: t Date: 2L" �l ! - off 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 I T Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)' \ Property Address: I,l 1� /f (• b! C, 0 ,�/��,� Owner: r Date of Inspection. ' Y � 'D Inspection Sumi iary:, Check A,B,C,D or E / ALWAYS complete all of Sectio D A. System Passes: 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: /-/ A One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally `unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or Gal 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 pipes) 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): ND explain: broken pipe(s) are replaced obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -Lo- I f- .Dunt /7'o P, (j.ONIv,W,k , W/1 Owner: t1l" r! // / r ' Date of Inspection: ��—r) C. Further Evaluation is Required by the Board of Health: N A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:' f it l ] b i Owner: IqL tr11, Date of Inspection: — 1 —OL D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No vBackup of sewage into facility or system component -due to overloaded or clogged SAS or cesspool _tf—Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool f 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 V2 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 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 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 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.] (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: A/ To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ — the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone. II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 • Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Pu, iron •� ,,rr�� r- 0 Al I-) t, V /- ) Owner:p( A,1 J, if Date of Inspection: 3 - 3 I -f 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 ? _1-� — — Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Z_ Existing information. For example, a plan at the Board of Health. _ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 ' Page 6 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 16 Dow -an oN -on DR, Owner: Date of Inspection: -3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder (yes or no): 3 r u 's ` J� Is laundry on a separate sewage system (yes or no):kLu [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)): (itl P Sump pump (yes or no): S Last date of occupancy: �� liro Y d 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: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: /,� ,V r" 5 Was system pumped as part of the inspection (yes or no): 4/ 1' S If yes, volume pumped: u allons -- How was quantity pumped determined? �_� w 7 — v c tc. /N Reason for pumping: ( r r �. �3:��rG� I + 7-14lyie • i,F S TYP F SYSTEM _ZSeptic 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 iliformation: Were sewage odors detected when arriving at the site (yes or no): � 6 , Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 f j'U j')(' ? P • C1 UCVC Ili<r Owner: H(. Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: 36 Materials of construction: _cast iron -"'40 PVC _other (explain): Di$,ttance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): / F. dU p 06 /f 0 l %/% /•I /w S SEPTIC TANKY (locate on site plan) Depth below grade: /�' y Material of construction: _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: �U �� A- S Sludge depth: ' Distance from top of sludge to bottom of outlet tee or baffle: 3 x - Scum thickness: / Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle;/ � How were dimensions determined: 40 / / S / 7-1-- Comments /Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _ 14,4 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.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: no x; '/t 1 ) Owner: Date of Tnspection: 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.): y�- s DISTRIBUTION BOX: (if present must be opened)(locate on site plan) 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.): No ri a 12 / o v -r✓ Z'& 14 PUMP CHAMBER: (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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 �N I N MI I. r) Date of Inspection: 57, - ! -o SOIL ABSORPTION SYSTEM (SAS): L' (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: 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.): �(. / L S G !2 /ly ✓ L ti Al p S X /-yLiL 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 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.): 2 o Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: )n P, i uU (;Q f ) 1,' k - ,\K • (11\N-( Ill' /1 P :r1 Owner:l`'jLn Date of Inspection: 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, k i�-C- 1,-),6,.. v 10 A Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0 0) (0141 U Owner: ! Date of Inspection: SITE EXAM Slope Surface water Check cellar D �z Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: �btained from system design plans on record - If checked, date of design plan reviewed: t/ 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: 19.1 6 -/ 17- 2 -IL 1 5- ' /16"I /,/r, W /5- i f r G i7 S f'r V Ho7,,/g o/' S'',7/ (C /�//,/rti /7 1, / ,'c" / [/�7 S G e-FI%ee 11 n r ' OF MASSACHUSETTS (J r �j ;E OF ENVIRONMENTAL AFFAIRS ENVIRONMENTAL PROTECTION BOSTON b4A 02108. (617) 292-5500 . TRUDY CORE Secretan• ARGEO Pj y /� DAVID B. STRUHS Governor Commissioner )SAL SYSTEM INSPECTION FORM 4RT A 1FICATION yg0G PY Property Adr me of Owner m RC1 �� S, Address of Owner��1�, Date of Inspection: �� ' � j- � Name of Inspector: (Please Print) Cr/v-4 / u5J4 1 am a DEP approved system inspector pursuant to Selection 15.340 of Title 5 (310 -CMR 15.000) Company Name: )ze /).O S J - Mailing Address: 1 r/ n r• r Solt L Telephone Number: - -r O u - 6 6 o' V:Z/ CERTIFICATION STATEMENT 1 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 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: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Datet6 -19-6 d 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 revised 9/2/98 Pagel of 11 0 Printed or Recycled Paper A I COTZ110ivW'EALTH OF MASSACHUSETTS 7 -,P EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON MA 02108. (617) 292-5500 . TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM AwPART A CERTIFICATION Property Address: / Name of Owner /.1 FC'.? /// f Address of Owner S'� , Date of Inspection: to _ � �� o v Name of Inspector: (Please Print) 510 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: �I IM /I Ae f10 S J-__ !l/r:• Mailing Address: -41_(04 J '✓ S--.,7 G Telephone Number: r U U— 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: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: / !1 !r Date6 r :?—,6 d 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 revised 9/2/98 Page Iof11 .. iii Printed on Recycled Paper ._ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Jwn�er:y Addres'yo P %/ OdDate of Inspection: !�( �► G l S �r�/2„ 61 — j — Q C3 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderat Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater j Feet 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) revised 9/2/98 a'r /9 -/'Sox- ''� HO Jt)~S Page 11 of 11 S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: Owner: Date of Inspection: %/ C� j / / r' -1 L INSPECTION SUMMARY: Check A, A C, or A A. SYSTEM PASSES: f-�1 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: /1 J r" B. SYSTEM CONDITIONALLY PASSES: +\A^ 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 / 1, CERTIFICATION (continued) v Property Address: / D a w C J Owner: �( A Date of Inspection: / ` " ' C'96 L. Is 1' i C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 1 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 1 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 than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / 0 9 G Ae C;) `t 14 Alb 0 U e n_ Date of Inspection: / 1� 4 L• S Tf �2 �� O 0 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 distributign box above ouet 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. 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 than 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 4of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Noperty Address: /b p �j �� arl A117 CV -e i - Owner: / Date of Inspection: i Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes 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 NIA. ✓ F The facility or dwelling was inspected for signs of sewage back-up, The system does not receive non -sanitary or industrial waste flow. l The site was inspected for signs of breakout. r.- _ 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. l 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)] The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION rroperty Address: / v p U .N� ��`^✓ 0 G r L Owner: Date of Inspection: �i GGt y rC/L FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedr o Number of bedrooms (design): Number of bedrooms (actual):_ Total DESIGN flow 12/� Number of current residents: Garbage grinder lyes or no): f S Laundry (separate system) (es or no): b, If yes, separate.inspection required Laundry system inspected (y s,Or no) Seasonal use (yes or no):0 Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no): Last date of occupancy:-25_rC V do. e COMMERCIAL/INDUSTRIAL: q� -/ Type of establishment: / Design flow: qpd 1 Based on 15.203) 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: lyes 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: ti S System pumped as part of inspection: lyes or no) If yes, volume pumped: (/ gallons Reason for pumping: TYPE 0 -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) I/A 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 lif known) and source of information: % Y� Sewage odors detected when arriving at the site: (yes or no) WD revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address:/ 12 G 1-i i=ce's 0!� Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:7 V Material of construction: _ cast iron -.-'40 PVC _ other (explain) Distance from private water supply well or suction line Diameter(/ Comments: (condition of joints, venting, evidence of leakage, -etc.) SEPTIC TANK:_ ej (locate on site plan) Depth below grade: 4� Material of construction: L"Cloncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge depth Distance from top of sludge to bottom of outlet tee or baffle: .3/ Scum thickness: .2 r. / , Distance from top of scum to top of outlet tee or baffle: 6 ` Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Qom/ S '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.) r ;:~ 1/' 77yu,, r c yr f GREASE TRAP: (locate on site plan) j Depth below grade:_ t Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness-.- Distance hickness:Distance from top, of scum to top'of outlet teer or baffle: - Distance from bottom of scum to bottom of outlet tee or baffle: Date of last 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 7of11 'roperty Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ] SYSTEM INFORMATION (continued) 'f Ui r 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: Yel _ No Date of previous pumping: A Comments: v t (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:yQS l (locate on site plan) / Depth of liquid level above outlet invert: d Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) k lo G S 1136 -le /" /' /''D at) r'a t /,9 i iii, r ' / Lam' w S 'r- X &t.-) / PUMP CHAMBER: -11A A (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 � ` t �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) 'roperty Address: p ,( �l �J /�/ r Jwner: Date of Inspection: r- `� 1. G/ S 7r4-- 1-3— 6 0 SOIL ABSORPTION SYSTEM (SAS):S (locate on site plan, if possible; exca tion 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: 40o 7< : overflow cesspool, number: Alternative system: '. Name of Te6hnology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan) Number and configuration' 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: _ �' J (locate on site'plan) 4 Materials of construction: 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 9of11 t 1 � ' ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )weer: } 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.111 9Q- 6-7 - 6-7 �u 92 revised 9/2/98 Page 10 of 11 3 A' TO: NOT,,T 1 MASS. BOAPD OF HEA T TH DESIGN ENGINEER Re: Soil Absorption FROM: Sewaqe Disposal System This is to certify that I have inspected the construction materials of said disposal,system at Site Location North Andover, Mass. The grades and construction materials are as specified in my plans and specifications dated and 19 19 C Reg. Prof. Engineer/Reg. Sanitarian — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — • : � ^'_•,. �;. .+'!.�'',x'fSNAli°1»}:Fra . *Rflr"`t ...11.3,&�'Sa.• ... �zK;d,Y=.0 < ...�r:�,.t r. ;r't' i{ k t 4 - ,. �. :.x ,. s ,� t FA Prorici 3: Tit1e/V Reg 2.5 rA.l r �e brdtted plan rcist uho:t as a r- zA m: a lot to be i of #, r,tatt .rs Location vnd log d, -op ob�;c:r .ratios to ties location and results peivolation tests -di atvace to ties -sign calculations & calculations show. -ung required leachi:cg rr a cation and dimensions of syutem-including reserve area existing and proposed contours g) location air v t a- e^s vithin 7001 of sewage disposal systcr:3 or �discl€iiz rr--chsck �, t'! �-ods i -1.,, !,ng h) •face end uubs-owfrco &-u-'Las viUl!n 1001 of a k -w s ci poeal r� ut --n or r i) Location VX,.Y ' r_ . .. its ., ""4-a =I of et-,po:�1 ,,-`u.j ut l or 01—uelc i., ;'J 3r files L3ak cD,; of 2.301 of m or Uscltinw �'t-e;%:U-v.tioa of z,, -j pr ✓posed :J1 to se -ve a_ot-1-031 from ? zacbing f,cility Oca'don of i tt�r ?'-a;ss on pmp€x ty -10 ' f1rom 1 rhd ug ft ::iLtty Pd cation of b:nohmirk iw"Mys �-bage disposals no PVC to be used in corat$v.ction q) profile of syvt--M-cL1ev-a,tions of bEse`=jvit, plunb, pips, c ptic t:.:,k, stribution box inlets and outlets, diutribution ficl_d p1pia; rnd /er elmrations r mm3eiv )i;= g.ound vatsr olc stion in ezea a_;,�.ge ss: m s) plan vast be prapa-%-c;d by a ProfvrA.nma I°or otli(;r prof 3�,siorwl r-utIo iz. d by law to p i , p, --re vu -c2: plans Reg 6 Septic Tanks a vpa..cffc;c-150% of flog, water table, V,.�;s, d --,Ah of tca�s, ecus, pu''?tag l c>:�out 701 Brom cellar *rr,1 or j.�„grouad si4z-gig pool d) 2P from submwface drains R Cg 10.2 tribution Pores 0.08 R -g 10.4 F ab) mav ulcurP�ce Bog 1-1. 2 U-4 11.10 11.11 Reg 15.1 15.4 15.8 3.7 Reg 1-4.1 14.3 14.4 14.6 14.7 14-10 Reg 9.1 9.6 . 71�-�rpa 2 Pits the is 4-,z�s--Vale pit:; P. d v,) cr7U:;a.I-aAtAzvis of 3<-- clj•'pq << _�'DO Lq ft b) LJaC:L'I,g c Lurfaca 4, -,,,a 2% d� uovar - oilal t A. ?lz&h pad 0 3 at CULIOW zo 1 -1 -ads in Pipa Lou cl--,c3x to pipe :- chin 171elds o grcator MO 20 r,%U=tos/Jmch -z-T-!M:U-3n 90-0 ati ft can: U-acUcn of Mald surface &-sinage 2 % e) 201 from collar inn or inground sulmming pool a) ciN�uta ons roT-Tviching arca-rain 500 sq ft ! 10� b) LPLCI idm 6 ft with resaive bAwwia 0 0 Ctj-o C) di-sasi ""Bi d) cw,.sctJ.on f) face ds 2% Tb-' -,jjjjU SIrLpe a) iEop6y1i - (to be diowa� b) y/xX 150 = (to be shova) P"S a) epproval b) stand-by pourar �41t ,i T Cfi 7� 7t f,., D � y.s .^1nl L� +l.�l a 'Y L 1.� iLi - - - i'.xv 4 A ( CrS 1. Diet:ance To! a. Wativlds b. Drains c. Well 2. Water Line Loi at: 3n 3. No PVC Pipq 4. Septic Tank a. Tars - Leag !% & To C L aan Out Co-,-ers b. Cement Pipe to Tank - On P-)th -"tales of Tank 5. Dis'cribijtion Box a. Co : ,•rs k Box - No Cra6r.a b. All Lines Flowing F-japl c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped ids d. Clean Double Washed Stone 7. Leach Pits a. Di.�u '-ons b. S 8 Depth lash Pads Teas e. Cep c4at Pipe to Pit - Both Sides f. Clean Double Washed Stone ,8. No Garbage D i spo sal -9. Final Grading Inspection 10. B?sricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e. k'ater Table TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATES -71-- d i w SYSTEM OWNER & ADDRESS SYSTEM LOCATION DATE OF PUMPING_ L "y QUANTITY PUMPED CESSPOOL NO ✓ / YES SEPTIC TANK NO__ _ YES v NATURE OF SERVICE: ROUTINE t/ EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY L COMMENTS: CONTENTS TRANSFERRED TO 1-9 Z S, �, // WELL DATABASE ADDRESS: AGE OF WELL: &I WELL DRILLER: WELL PER YET T: WELL LOCATION:�.✓, WELL PERMIT DATE:— ,2 7 -/ DEPTH OF WELL: TYPE OF WELL: a . DRIT.L,ED b. DUG c.U OWN TYPE OF WATER BEARING ROCK:. WATER ANALYSIS DATE. ? HIGH �GANESE: Y N HIGH IRON: Y N OT=CO ANTS: Y N WELL DATABASE ADDRESS: AGE OF WILL: G WELL DRILLER: ? �' WELL PERNET R: ? WELL LOCATION: SELL PERMIr DATE: �' — -- DEPTH OF WEIRf� TYPE OF WELL:__. DRILLED b. DUG { UNX OWN TYPE OF WATER BEARIN(a ROCK- 2 WATER ANALYSIS DATE: HIGH (MANGANESE: Y HIGH IRON: Y N OTHER AMINANTS: Y N )j� ��r