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HomeMy WebLinkAboutMiscellaneous - 100 CROSSBOW LANE 4/30/2018lIO_ 1 o o C'):• W o o co N co O W Ob f o Z J o m d• Q LA 0 m 0 El w A-li U o xNa .� v • a 6,4) LAI .d- o� _/ '= fa RO •'ice,, � CG„�;=`�.. s s 1.” 0 yfi 1,r° L i1,6(4h ANL)6Ver 12-6.4. )fid Mo►n St, No,lfh A Iibet/e�' caul LEc 151—m FF )''n s'-i'C4 l! L� # i� J I -wHfT, I / HI YLV NGf,. MSgART' S SEPTIC TALC SMaCE 47 R TROAD SPREer H'ADFORD, MA 01835 978-372-7471 MOMM OFMOM MY REPORT FOR TOWN OF 1 ) f - - �� ; > ✓ DATE h r P411;JC UL /V�/VJ/l.JJ/ VV. JV .1V VJ/JV V11 I; i1,6(4h ANL)6Ver 12-6.4. )fid Mo►n St, No,lfh A Iibet/e�' caul LEc 151—m FF )''n s'-i'C4 l! L� # i� J I -wHfT, I / HI YLV NGf,. MSgART' S SEPTIC TALC SMaCE 47 R TROAD SPREer H'ADFORD, MA 01835 978-372-7471 MOMM OFMOM MY REPORT FOR TOWN OF 1 ) f - - �� ; > ✓ DATE h r P411;JC UL Board of Health - �>a BEPTIC SISTEM North Anc_overzMaas. 1:av / INSTALLATIO9 CHECK LISP LOT ' J ' APPROTED DATE �,� to �arrxuy r u r ,FAIL DATE Ga..._ vCi:7wWi �_- 1. Distance Tot a. Wetlands b. Drains c.. Well 2, Water Line Location 3 No PVC Pipe /� 4. Septic Tank a. Tess -_Length & To Clean Out Covers b. Cement Pipe to Tank On Both Sides of Tank / 5. Distribution Box a. Covers k Box - No Cracks ' b. All Lines Flowing Equal- Amounts c. No Back Flow 6. - Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimas ons b. Ston Depth c. Sp sh Pads e. cement Pipe to Pit -Both Suedes f. Clean Double Washed Stoi 8. No Garbage Disposal b .3j 9. Anal Grading Inspection � 10. Barricading Covered System :1.. As Built Submitted 13 a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations ` F . e-. e.. Water Table TO: FROM: NORTH ANDOVER, MASS BOARD OF HEALTH DESIGN ENGINEER Pe C Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at L a o'a c'W North Andover, Mass. SITE LOCATION The grades and construction are as specified in alpy plans and specifications dated Board of Health N a rti::�n do ve r, ?Sas s I SUBSURFACE DTSPO L DE, GN CHECK LIST APPROVED DATE ' Provided: � DISAPPROVED Reasonst DATE LOT # ►S GP.csS_?SoW r Title V FAIL CK Reg 2.5lb he submitted plan must show as a minin mt a) the lot to be served-area,dimensions lot #,abutters location and log deep observation hoes -distance to ties b location and results percolation tests -distance to ties d design calculations & calculations shooing required leaching area ) location and dimensions of system -including reserve area ) existing and proposed contours location any vat areas Athin 100' of sewage disposal system or sclaimer-check wetlands mapping (h surface and subsurface drains within 100' of sewage disposal system or disclaimer (i location any drainage easements within 100' of stege disposal system or disclairr�er-Planning Board ilea (j) kno= sources of water supply within 200' of serge di spot- d _ system or disclainer k-) location of any pro�osed_we l to serve lot -100! from leaching facili' location of kater lines on property -10' from leaching facility () location of benchmark drivevays garbage disposals no PVC to be used in construction q) profile of system -elevations of basem- , plumb, pipe, septic tangy:, distribution box inlets and outlets, distribution field piping and otter elevations maximum ground water elevation in area se -;,age dis__ system (s) plan mast be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6 Septic Tanks a) capacities -150% of flow,, water table, tees, depth of tees, access, pumping cleanout rd) 10' from cellar imll or inc-round sng pool 25' from subsurface drains Reg 10.2 Distribution Boxes () slope greater than 0.08 Reg 10.4 b) sum E r.,o d �o� Q�ESf��/f; So Cf `✓ L00 oNQ•L w� ��" �lvQ� n~' -gyp> o�C�sti , Coe"-spow" �� Urr14 Lc" r- t b Design Check List FAn I M I Leaching Pits ' Leaching pits are preferred where the installation is possible a) calculations of leachin ea -minimum 500 eq ft b) spacing c) surface drainage d) cover materi e) VxV x4p ash pad f) tee at bow g) no ds in pipe from d -box to pipe Leaching_ Relds raregreater than 20 minutes/inch a -m ni mr�zm 900 sq ft of field Vffurface drainage 2 % e) 201 from cellar va11 or inground swinxdmg pool Leaching Tr-mches ,a) calculations eaching area -min 500 sq ft ;b) spacing -4 min 6 ft with reserve between ,c) dimen s d) co action e) ne snrfacs dra' age 2% Do-olhill Sloe _ sopeyx= to be b) y/x X 150 = (to be Puny a) approval b) :,tjInd-by power Page 2 Leaching Pits ' Leaching pits are preferred where the installation is possible a) calculations of leachin ea -minimum 500 eq ft b) spacing c) surface drainage d) cover materi e) VxV x4p ash pad f) tee at bow g) no ds in pipe from d -box to pipe Leaching_ Relds raregreater than 20 minutes/inch a -m ni mr�zm 900 sq ft of field Vffurface drainage 2 % e) 201 from cellar va11 or inground swinxdmg pool Leaching Tr-mches ,a) calculations eaching area -min 500 sq ft ;b) spacing -4 min 6 ft with reserve between ,c) dimen s d) co action e) ne snrfacs dra' age 2% Do-olhill Sloe _ sopeyx= to be b) y/x X 150 = (to be Puny a) approval b) :,tjInd-by power SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No CEO Lot No l5 Loc/Subdiv. -Z�� ��-s , _ . Prl and Owner Investigator B ��3� Observer Al�rz ale v // ✓•--J SOIL PROFILE DATES 1.I;lev 2.Elev 3.Elev 4.Elev �llz.9I83 4'z9 �B3 �oSS wars I+J ' 0 S�3/�b 0 T 0 TP. 'L 0 1 1 1 1 2 2 Te S 2 T S 2 3 3 3 3 4 4 4 4 0 5 '3ovCS 5 �, 4 5 73t ,-6-Y �. 5 7 7 7 a 7 8 8 8 8 'R�o s o.L. 7E Benchmark Elevation 9 9 9 10 10 10 Location Datum PERCO;,ATION TESTS ' DATES A 1-7 4 t P 3 7/P,0c? � 0A1. � r Tiles P- 1 est ns Fee Pit Number 1 2 Start Saturation M331 Soak-Minutesw Start e Drop of 3" -Time 3 5 q C Z Drop of 6"-Ti.me M ms.lst 3" drop 1'It, 1iK►•� Mins.2nd " DropO Percolation 17 NEW ENGLAND ENGINEERING SERVICES INC lk / . AUr, 1 0 ?004 Tow E( UR7H ANDOVER RjH;ENT August 9, 2004 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: RE: 101 Crossbow Lane, North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Bnjamin C. Osgood?Or Certified Title 5 insp 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE S 'OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: \ . (.YO -SSM l 1 Ln. A" (Ski 2Y , M .1. 1918 U 5 Owner's Name: 4 ayna T� V q\< Owner's Address: i D 1 =L 55 ow L N Date of Inspection: 9� Name of Inspector. (please print) Beni amin C. Osgood. Jr. CompanyName:New_ England Engineering Services Inc. mading Address:60 Beechwood Drive, North Andove ,MA 01845 Telephone Number: 978-686-1768 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 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: Date: 9 ay 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. Page 2 of 11 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTA. CERTIFICATION (continued) Property Address: TA YOSS 6W "() Yth Owner:C�yTU Date of Inspection: Inspection Summary: Check A B C,D or E / ALWAYS complete all of Section D A. System Passes: " t _ 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: scribed m the "Conditional Pass" section need to be replaced or 11i,2 One or more system components as de repaired. The syn, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,NM) 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 exfiltmuon 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 oval of Board of Health): th). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: 1 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: M55bQ >J Lp, \O\t r.rt MG- 01IF3'A4 ) Owner: Date of Inspection:3 IS 100 Q Farther Evaluation is Required by the Board of Health: -AZOL Conditions exist which requite fiuther evaluation by the Board of Health m order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(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 sod within 100 system (SAS) and the SAS is w 100 feet of a surface water supply or tn'butary to a surface water suppler. _ 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 ormore 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 iodic ates that the well is free from pollution from that facility axtd 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 l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: J 0 � (mS5 h O 1 I h Owner; MCA_ G 18y5 Date of Inspection• U D. System Failure Criteria applicable to all systems: You must indicate "S+es" or `Sao" to each of the following for all inspections: Yes No _ f 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 t/. 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a privatemater 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 ata 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 mast be attached to this form.] (YeslNo) The system fails, I have determined that one or more of the above failure criteria exist as dibed in 310 CMR 15303, therefore the system fails. The system owner should entad 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 1Rd- You must indicate either'W or "nor to each of the following: (The follow1 nig criteria apply to large systems in addition to the criteria above) yes no the system is 400 feet of a surface drinking water sup the system is within 200 of a tributary t ce drinking water supply the system is located in a en itive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a pub ' ter supply well If you hav veered "yes" to any question in Section E th em is considered a significant threat, or answered in Section D above the large system has failed. The own r operator of any large system considered a significant threat under Section E or failed under Section D shall up de the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional offic f the Department. Page 5 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _Id1 C�CSSbo� I I h. Owner: JL Date of Inspection. o Check if the following have been done. You must indicate `files" 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 now as NIA) _ Was the facility or dwelling inspected for signs of sewage back up ? t! — Was the site inspected for signs of break out ? Were all system components, excluding the SAS, looted on site ? Were the septic tank manholes unoovered, opened, and the interior of the tank inspected for the condition of the baffies ort material of construction, on, dimensions, depth of liquid, depth of sludge and depth of scam ?. _ Was the facility owner (and o=Vwts if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? i The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _ Existing information. For example, a plan at the Board of Health. _ .Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 1310 CMR 15.302(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: (ot lr� t MY -V 01W Owner: b4 yW Date of Inspection: �S _ 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): No Is laundry on a separate sewage system (yes or no): _Jes f if yes separate inspection required] Laundry system inspected (yes or no): — Seasonal use: (yes or no): _ Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): Last date of gpcc as cy: _ ---i-- -- COMHiERCIALMDUMIAL Type of establishment Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgftetc.): 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 (descxibe): GENERAL INFORMATION Pumping Records Source of information: U iV K n10 w Aj Was system pumped as part of the inspection (yes or no): �p If yes, volume rimped: _gallons — I1ow was q mntity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) — Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no):/V 0 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection. _) BUR DING SEWER (Locate on site plan) Depth below grade: 3 �t Materials of construction: -1 cast iron _40 PVC other (explain): _ Distance froth private water supply well or suction line: comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ (locate on site plan) Depth below grade: i S5 f Material of construction: _concrete metal fiberglass _polyethylene _other(explaia) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a spy of certificate) Dimensions: F.� oo Sludge depth 3"1 Distance from top of sludge to bottom of outlet tee or baffle: 3a Scum thickness; _ Distance from top of scum to top of outlet tee or baffle: to Distance from x bottom of sarin to bottom of outlet tee or baffle: How were dimensions determined: rn ec.s G s -n , 14, 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) 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 umpingComments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page g of 11 OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ..Property Address: 0 L n �- a i M a. o � ay5 Owner: , e , A Date of Inspection• �_= TIGHT or HOLDING TANK:44 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimarsions• CApachr. gallons Design Flow: gallonslday 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.): DLSTRIBUTION BOX: ,� rif present must be openeVocate 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.): ins C) (4 (-6 Jnr a 2 PUMP CHAMBEIt:�✓c4 (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: Y OSSb 6w LY1, tJeV� Ah�l rPr. HiQ, 01�►-1� Owner: Yk 2" Date of Inspection; O` SOIL ABSOPIMON SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type. leaching pits, number: _ leaching chambexs, number: leaching galleries, numbw leaching trenches, number, length: _ham leading fields, number, dimensions: t F Gc n as" X 36, . overflow cesspool, number: innovativelalternative system Type/name of technology- Comments echnologyComments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)- A4E Ig 14s YX Ag A L CESSPOOLS: AJA- (Cesspool must be pumped as part of inspectionkocate 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 ): PP"y: IM -(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): ' Page 10 of 11 OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: t b 1 Cy C5-�, ho k k 1 Ln . Nov`t�n ��nrin�lP�r M . G1Q,U5 Owner: �l n V� 1 Y G 1C e,l-eJ�/� Date of Inspection. L 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. e 205532) .-- I.AQvr Ig' I kaoU, Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:` c)i, �n ��Y�-Y, Qnrl�yPr Nta. a�8�1S Date of lnspectionr�_A l q I Ot-1 SITE EXAM Slope Surface water Check cellar Shallow wells . Estimated depth to ground water 1-j feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You mast describe how you established the high ground water elevation: k- 4q -Fa t % iF lb'w p r7)D 0 F y' e C ca w 4:jL1FW a i- �,v v CommonweaUh of ,M System hot$ System 0,Amer IY7,,Y Q/e,4 , 11214 FORM 4 - SYSTEM PUM MNG RECORD CEIVED AUG 10 2004 HEALTH Type: Emergency ❑- Routine E� Cesspool: No Yes ❑ Septic Tank: No , [] Yes Date of Pumping: /dt -6 Quantity Pumped: IV gallons System Pumped by (Company): ' - c ! Permit #: Contents transferred to: Contents disposed at: - Date 2 -id D Pumper Signa Condition of system/other comments: DEP APPROVED FORM -12107195 FORM 4 - SYSTEM P[3 VEMG RECORD i Commonwealth of Massachuseus , Massachusetts System Pum.ift Record RECEIVED AUG 10 2004 / / r(� G� ✓e �1 o TOWN OF NORT Type: Emergency ❑_ Routine & . Cesspool: No ® Yes ❑ Septic Tank: No ❑ Yes Date of Pumping: Quantity Pumped: Aj 4,1*� gallons System Pumped by (Company): Permit #: Contents transferred to: Contents disposed at: Date Pumper Signature Condition of system/other comments: FORM 4 - SYSTEM PUMPING RECORD Commonwealth of Massachusetts , Massachusetts System Pumping Record L EIVED10 2004 NORTH ANDOVER DEPARTMENT Type: Emergency ❑. Routine ❑ Cesspool: No Yes ❑ Septic Tank: No ❑ Yes �. Date of Pumping: 2-,210 -6 % Quantity Pumped: /A&() gallons System Pumped by (Company):� v Permit #: Contents transferred to: Contents disposed at: Date - •- Pumper Signatu7~ Condition of system/other comments: FORM 4 - SYSTEM PUMPING RECORD y commonwealth of Mass"husett RECEIVES Massachusetts Svstea►t� P�um�rninAUG 10 2004 ystem Owner System ocaUon HEALTH DEPARTMENT 0 ?ej� j E ?S- 71—,I—r l�of%t, s r n!' AiAd►le-r, PA Type: Emergency ❑_ Routine Cesspool: No Yes ❑ Septic Tank: No ❑ Yes �. Date of Pumping: -,26-0Quantity Pumped: // �,(�gallons System Pumped by (Company):2)g&j Permit #: Contents transferred to: Contents disposed at: Date 7,,0 -_ay Pum- Si atu Per gn Condition of system/other comments: William F. Weld Governor Argeo Paul Celiucci U. taoremor Commonweafth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Ro CI CoQ Trudy Cox&,—.- -_ Secietery B. Struhs CommMioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A „, r /�RCwERTIFICATIO,�N/� Property Address: � ©o 0eoss co) L w� _ ` ddress of Owner. Phte of Inspections ( — if different) Name of Inspector. Company Name, Address and Telephone Number. BATESON ENTERPRISES, INC. TEL: (508) 475-1474 6cc2vating - Water & Sewer Lines - Septic Systems & Pumping Service FAX: (508) 475-5451 CERTIFICATION STATEMENT 111 Argilla Road ■ Andover, Mass. 01810 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 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: `� Lasses Conditionally Passes R,,.- Nth I't nher Evstlu ation By the LacW Approving Authority i — F' Inspector's Signature: Date: -213-- The System Inspector shall submit a co of this inspection report to the Approving Authority within t /hirty (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. INSPECTION SUMMARY: Check A, B, C, or D: A] SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. I3) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 AL One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500 ire Printed on Recycled Paper M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address oo C L _ 00<t &JOJQA— Owne r. ,{ (JIA, I 1 �! QAA PRO 'Bf Ihop"tiona BI SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(o) 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(a). The system will pass **pWion if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER 'WHICH WtLt, PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMWM 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil<gbsorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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. 3) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I ©C) �} 'MS bUUQ t.._OLAAC) �J©CA�A "JQN- Ownerl Date of Inspection: 1 1 w a.a�.) ( I'Q C,AA D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. 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 1� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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. El LARGE SYSTEM FAILS: 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: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address l,l c Nd r`t V \ l Owner.` � Date of Inspection: � ` � � ^ Check if the folio ing have been done: Pum' information was requested of the owner, occupant, and Board of Health. N� oae of the system components have been pumped for at least two weekx and the system has been receiving normal flow rates d t period. large volumes of water have not been introduced into the system recently or as part of this inspection. 41A plans have been obtained and examined. Note if they are not available with N/A. As p e�hem fa ' ity or dwelling was inspected for signs of sewage back-up. m does not receive non -sanitary or industrial waste flow was inspected for signs of breakout. �'components, excluding the Soil Absorption System, have been located on the site. t/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or Ze terial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. and location of the Soil Absorption System on the site has been determined based on existing information or app ted by non -intrusive methods. _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. i I (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ��--yy�� j�_� ' SYSTEM INFORMATION Property Address: i O C' (oSS LISW LC�Me.. 00CAAP, 4V,&Ua(- Owner. �`'� �k I ) `i QM Date of Inspection: FLOW CONDITIONS RESIDENTIAL; Design flow: 94o ns Number of bedroozns:��t Number of current residents. Garbage grinder (yes or no):E3 Laundry connected to (yee or no):�s Seasonal use (yea or no): �" � Water meter readings, if available: Last date of occupancy: �f"44 COMMERCIALANDUSTRIAL: Type of establishment: Design flow:----gallons/day 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: I Lom date Of ipanty;_ OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ouv\pA— System pumped as part of inspection: Qves or no)-VA If yes, volume pumped: �lJroO gall o Reason for pumping: h S� I TYPE OF SYSTEM ✓Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) "PRO=AGEof �mponents, date installed (if known) and source of information: r 1Q _ 00 ID -31-63 Sewage odors detected when arriving at the site: (yes or no) k/O (revised 11/03/95) s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address 0d &(-a% llv L _ (- VA Viers M c' CLL, I I V CVA Date of Inspection: SEPTIC TANK: t.-' (locate on site plan) tr Depth below grade: ( a Material of construction: Vconcrete _metal _FRP —other(explain) Dimensions: 1 C� X X ?� 7 • , _ (`J �q Sludge depth: d ' l " Distaaee from, tap of alfdeo to lteoom of outlet tee or baffle:O Scum thiclmess: 6 � r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle; Comments: (recommendation for pump condition of inl t and outlet � s or evidence of leakage, etc.) ,�� ` LS2 ` . ` GREASE TRAP:jCj©v&e V (locate on site pian) I Depth Below grade: Material of construction: _concrete _metal _FRP —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: r of to outlet invert, 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 11/03/45) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,, ��— Property Address 24 QV Owner. Date of t •I"tlom TiGHTIOR HOLDING TANK: nOt-\e— (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: capaeitys rnllat Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: C� Comments: t r (note if 1 1 an dist 'bunion is equal, evidence of solids er, evi encs of leakage into or out of e ) ��S'c- va( 1icc( ov C_ vvx --d PUMP CHAMBER:�'\0V'e_ — (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM ,�INFORMATION (continued) Property Address: j � CcoS"SOW L -o `� � O O `'� Owner. � v . OOLA�, S, 001 kto of Irrd( b b"I `'3' ?, � , q / SOIL ABSORPTION SYSTEM (SAS): l% (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Ali= leaching pits, number:_ leaching chambers, number:_ leaching galleries, number leaching trenches, number,length:��-� 1 leaching fields, number, dimensions: overflow cesspool, number: — CESSPOOLS:JW1k�O (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 (cesspool must be pumped as part of inspection) r Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: V\ OVW- (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.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (oon/t(in�ued) Property Address: ' oo C��S � NO � "� "UQ4- Owner. 044 tit lowsp*0116M SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: (revised 11/03/95) r; V2 uJ a, f-V0,j,P-Q r, 9 T, 3a