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HomeMy WebLinkAboutMiscellaneous - 1005 FOREST STREET 4/30/2018 (2)I l Commonwealth of Massachusetts Executive Office of Environmental Affairs Department 'of Environmental , Protection 1 1 , li�, 0 - 14, co�� William F. Weld Trudy Coxe Govemor S.cretary Argeo Paul Celluccl bavid B. StrUhs U, Gammor Gommnaanar SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATI N I Property Address: /ons � -FoceA sk ddresa of Owner. Date ofse ion; e�� S�� s (If different) ma Name of Ins tor. Company Name, Ad ress and Telephone Number, BATESON ENTERPRISES, INC. TEL: i3013)4-5-14-4 Ercacating - Water S Sewer Lines - Septic Systems d Pumping Service FAX: 1508) 475-3-451 CERTIFICATION STATEMENT I 1 1 Argilla Road Andover, Mass. 01810 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 ' posal systems. The system: _ Passes _ Conditionally Passes — Needs Further Evaluation By the Local Approving Authority _ F Inspector's Signature: ate: The System Inspector shall b 4,.0this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A. B, C, or D: A] SYSTEM 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. . B] 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 meW, 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 Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street a Boston, Massachusetts 02108 .e FAX(617)556-1049 , e Telephone (617) 292-5500 i' Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: B] 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(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 Healthy ' , k , broken pipe(s) are replaced C obstruction is removed C) FURTHER EVALUATION 1S 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 em-ironment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: i 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) s 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 absorption 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) 2 S . o , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: too -!5 01�-es�-"Z4, I o �-4 V\ Owner. Date of Inspection: H D) SYSTEM FAILS: R • `f 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. j Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(e). 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: 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 II 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) 3 % SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: C �Q '-3� Check if the following been done: _ ump' rmation was requested of the owner, occupant, and Board of Health. _ None of the s m components have been pumped for at least two weeks and the system has been receiving normal flow rates d period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As have been obtained and examined. Note if they ars not available with N/A. _ The f ' ' y or dwelling was inspected for signs of sewage back-up. The does not receive non -sanitary or industrial waste flow e si as impacted for signs of breakout. _ All in components, excluding the Soil Absorption System, have been located on the site. _ The septic manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of bailles or terial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ;The size an ocation of the Soil Absorption System on the site has been determined based on existing information or app I ted by non -intrusive methods. e facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 11 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION,�- Property Address: Owner. Date of Inspection: FLOW CONDITIONS Designtlow: ' C7 gallons (ion 0� l loU f b�� � C -w. c� Number of bedrooms: _ s Number of current residents. Garbage grinder (yes or no):�25 _ Laundry connected to system (yes or no):--ye— Seasonal use (yes no): �l/O ©V\ we -11 5 � C'_ a Water meter readings, if available: ` ��p-"(' Last date of occupancy. COMM ERCIAL/INDUSTRIAL.• Type of establishment: Design flow:_gallons/day f Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ r ! Non -sanitary waste discharged to the Title 5 system: (yes or no)_ , • / , Water meter readings, if available: ! Last date of occupancy: OTHER (Describe) Last date of occupancy: PUMPING RECORDS and source of information: GENERAL INFORMATION System pumped as part of inspection: (yes or no) eS If yes, volume pumpe4: G ons 1,� Reason for pumping: 1�1A �, wC/A_QS� TYPE ptic 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) CJ- aUhe.-f' APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yea or no) , (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION jj (continued) Property Address: ' 0C)s "R�2S4 Owner. r Date of Inspection: -'�V -�-J�► ` `� SEPTIC TANK_V (locate on site plan) f� '1� l•e, CdvQ.A" 9 Depth below grade.. Material of construction: �L-concrete _metal _FRP _other(explain) Dimensions: ►'7 ' X S X 7• 5_ = / '>,q C ( (CNIS Sludge depth_ 7 1/ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scusn to bottom of outlet tee or baffle: Comments: (recommendation for pump' conditiopn^n of �' et and outlet tees pPr _b�af� let,—depth of liqui level in relation to outlyt invert, evidence ofleakaee,etc.) 1)t-AM14�� P C—q=., . v�r� be.�Ae-.CJf1. r1C GREASE TRAW It (locate on site plan) 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: ! 1 l 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 11/03/95) 6 ,4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oo tinu Property Address: 1005 S� 1 VO Owner. Date of Jnsp!ectlort: �— I r TIGHT OR HOLDING TANtt,-12�0nl°s (locate on site plan) Depth below grade: Material of construction: —concrete _metal _FRP —other(explain) Dimensions Capacity: ¢allons �t - i Design flow: callonsiday ' Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) t DISTRIBUTION BOX - ( (locate on sit* plan) Depth of liquid level above outlet invert: 0 Comments: PUMP CHAMBER no Y�2 �S44V , (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) NO (revised 11/03/95) 7 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION �((cc�onntinXJou", d Property Address: � �°C� � � "0 O ' " ` (continued) Owner. PA r, R Date of Inspection: _ G�� " ) SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number;,_,,,,,.. (notendition f soil, signs of hydraulic failure, ^cc T , Kjr�' a 1n C CESSPOOLS: LOV\e— (locate on site plan) of vegetation,ete.I 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) 9 � t f Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: Mov? ' (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) 8 ` ' do SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORM�ATIIO�N (oontinued Property Address: ( A. Owner. Date of Inspection: V v S`l�- SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' A- -V0 'a,) A- i -V S ,4 - o ,4- 4--0 a- -:�-3a' e).AZD S) = DO'6rz�4.3 Sa9z V--ex-+x - C�-3 yL/ - DEPTH TO GROUNDWATER Depth to groundwater: iL, set method of determination or aporoxir u� A (revised 11/03/95) 9 . a -f- 4 7 _ L ,,COMT NTAEALTH OF MASSACHUSETTS pi EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON MA 02108 (617) 292-5500 TRUDY COKE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION /--ST Property Address: j%� S (J Name of Owner/��%�,� f Cly �%/ rA0 0 ✓ Address of Owner: Date of Inspection: S R O S Name of Inspector: (Please Print) 1 am a DEP V proved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 15.000) Company Name: /ft( o b S . iq 4 /C- Marling Address: — 4.7 Telephone Number: 7 Y -7 f 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: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails inspector's Signature: "� Date: —0 Q 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 n� r revised 9/2/98 Pagc1of11 C6. Pnnied or Recycled Paper s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Noperty Address: Da f 0 T Owner: -2 712 Date of Inspection: INSPECTION SUMMARY: Check A, B, C, of D: A. n SYSTEM PASSES: 1, I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: 146 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 1 revised 9/2/98 Page 2of11 /,/7/ a''7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /Q D �(� j2 r- T S, 1`1 %'i 'I d d k/ Owner:n Date of Inspection: 'Y -F'2 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: t 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. 11 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 LAND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER r ' I revised 9/2/98 Page 3of11 v L. •° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: 1 Qo�ST --Kp� Owner: _ Date of Inspection: J l? i 4r �— I Q 0 L D. SYSTEM FAILS: . You must indicate eit er Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility- or system component due'to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater 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: 8A. - You must indicate either "Yes or o" 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 Y F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �d0 �G���r}loov Owner: Date of Inspection: 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. _ N As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non -sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) The facility owner (and occupants, if different from owner) were provided with information on the proper maintenaaca-of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: � �� � c... Owner: 6o S T! Q e'S'f At, 0,0 V Date of Inspection: 3"j. 0 U FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design)- Number of bedrooms (actual): L/Total DESIGN flow 13 Number of current residents:_ Garbage grinder (yes or no):�5 Laundry (separate system) les or noJ10 ; If yes, separate.inspection required Laundry system inspected ( es or no) Seasonal use lyes or no):%+ u Water meter readings, ifav 'lable (last two year's usage (gpd): I J,/ Sump Pump (yes or no): —#-9 / Last date of occupancy:��L^6 d a . COMMERCIALIINDUSTRIAL: 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: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)419� If yes, volume pumped: 1 V gallons Reason for pumping: l I vL T 4 J. o TYPE OF S TEM eptic 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 Of known) and source of Information: I)(, ► [, ( JI-) Sewage odors detected when arriving at the site: (yes or no) J7 revised 9/2/98 Page 6of11 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) s T l t/49d V. 3-111-04 Depth below grade:7-4, ` 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: (locate on site Depth below grader Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 4 r�? (v X � t/ Sludge depth: t l t1 r Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:_ <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: How dimensions were determined: 1) X1 S 1 7 r '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.) uFF�rs � Tf�iyr� boa c:r Nei T/ur✓ 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 tb top of outlet tee 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: �Q % G J2 S?r /� / pe t�v Owner: 1%,� ? ,Z Date of Inspection: / � TIGHT OR HOLDING TANK/ f "I � 11 (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:' (locate on site plan) Depth of liquid level above outlet invert j�V / Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc. fSu�i 7(_d ,n Jej)" r/rfs/ /'9/ '7 'r OC 4 vP /G fi77'tc' PUMP CHAMBER:_ (locate on site plan) ' M1. Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /�O � SYSTEM INFORMATION (corttirwed) � �� 4operty Address: / v 1'r6T S- /;~/ N Jwner: Date of Inspection: f %/2 < < % SOIL ABSORPTION SYSTEM (SAS):Q5 (locate on site plan, if possible; exca ation not required, location may be approximated by non -intrusive methods) If not located, explain: Type leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ 2 ' leaching trenches, number, length: 3 leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of+Technology: ) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) S ti -/OJT A<o o ��utl fe 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: _ 14 A (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 9/2/98 Page 9of11 s. 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 1 6 Q � r •� f f ` N (/ U `' /'' )weer: Date of Inspection: ( /,I A ,/t C 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) k i P 3� O -P _ 4; r revised 9/2/98 Page 10of11 s I.f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j �+c SYSTEM INFORMATION (continued) operty Address: / 6d �n t Y Jwner: r Date of Inspection: f' IC o— _ /U d NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells J( 1 Estimated Depth to Groundwat41 Peet" Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 0,0,9'erved Site (Abutting property, observation hole, basement sump etc.) L///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) Pu '' p pco ti+ /.I- T 616 J.4� rA, 4 r , T A ,3i, r revised 9/2/98 Page II of II 9 G (w /-j M c lC (/ /- /r -'l d --f- 9 C I APPROVED Date:, ( P" NORTH ATTIDOVLR BO.kRD OF H''P.LTH / v C 1iv5?r.LAI'10N t,ii. tK LIST - - _ __ DI S.0PROV D -� �r - EXC AVA'i I ON OK Date: Reason: 1. As Built Submitted Check: Lot ation, dimensions, of system, location in regard to P colation tests, depth of system, water table l �� 2. Distance to Wetland Areas, Drains, Street & House, Drainage Easement and Wells. 3. Water Lane Location 4. No PVC ipe 5. Septic Tankes Cement -P' to Tank -Joints on both side of Tank. 6. Distribution Box - No cr sinor co r, all lines c}l371y .from box. 7. Leach Fields - Dimensions, Stone Depths, Capped ends, Clean double-i-Tashed stone 8. Leach Pits - Dim sions, Depth,,. ne S ad,� tees, emert-pipe/otank- joints �on both sid` f`�t _ Cl e- sh d stone 9. No Garbage Disposals 10. Final Grading ".barricading of sub -surface system! TO: NORTH ANDOVER, MASS BOARD OF HEALTH FROM: DESIGN ENGINEER �a- 19 ;7 % Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at co EO z,Es % S T I North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 1Zt�'„ f., gineer/R'eg; nitarian /A f "4 I TlenAl h: �7 13 o x IAI9t7-46 -3o X OU 7— 973( JIV P/ //v P1 r,(3 /A f "4 I SOIL PAOZxLE & PERCOLATtON TEST DATA Town Ci y,�_ Nn.&Street Dr �,%}� . Lot N o. Loc. /Subdiv. 1 Owner ,may f or Investi at V 9 Q/� Observed p 77 SOLL PROLES -DATE l81% -- Elev.2' Elev,Elev.....— 4 *-Elev. 0 -r 0 0 . 0 10 �_ Benchmark Elevation 1 2 3 4 5 6 3 ) 8 9 10 1 2 3 4 5 6 7 8 9 10 Location Datum Percolation Tests -Date 1 2 3 4 5 6 7i 8 9 10 Pi t Number � 2 3 4 S Start Saturation Soak -Mins. Start Test -Time Drop of 3" -Time Dro of 6" -Time Mi.ns.lst 3"Dro , Mins.2nd 3"Dro �._L_ uc .nc1.411CD vu nac,c r•ranx c. Gelinas & Associates, North And. V � 8 5, 5 � , i 0° �, PrP A I V -10m O a 4 f{ --ZD7 GL 1 7 en \� V/7—Z-7—ya ; ,OOQ 41...`�� �� c � . �,� ' ^ r SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass: Str&et No �_G7�% `7� Lot No Loc/Subdiv. Pland Owner l�?C Investigator Observer r SOIL PROFILE DATES 1_El.ev 2.Elev 3.Elev 4.Elev 0 1 2 3 4 5 6 7 8 9 9 10 10 Benchmark h1�. Location Elevation Datum PERCOLATION TESTS DATES 0 0 1 2 3 4 5 6 7 8 9 10 Ti-esPt sTest Pit Number 1 2 3 4 �3 Start Saturation Soak -Minutes Start • e Drop of 3" -Time Drop of 6" -Time Mcns-Ist 311 drop Mins.2nd " Drop Percolation (D O -n E N to (D C rt O O A v O n 3 D O� O r�r I co Dvv n a* o c c� 3 rt �oc�a m � � � � C C -t 'o 0 m o, v 0 A C rt D 0 3 a >3 (D O -n E N to (D WELL DATABASE ADDRESS: �r 51-7"— 3 AGE OF WELL: ? WELL DRILLER: l WELL PERL\vIIT.: ? WELL LOCATION: ._ WELL PERMIT DATE: DEPTH OF WELL: ? TYPE OF WELL: a.. DRILLED b. DUG C. UNKNOWN f TYPE OF WATER BEARING ROCK: f� WATER AiNALYSIS DATE: HIGH MANGANESE: Y HIGH IRON: Y N OTHER CONTAIMIlVANTS. Y N WELL DATABASE ADDRESS: /0 / � C &�4— " ' 2 AGE OF WELL: WELL DRILLER: WELL PERMIT �: WELL LOCATION: WELL PERMIT DATE: DEPTH OF WELL: TYPE OF WELL: a.. DRILLED b. DUG c. UIN-K OWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH MANGANESE: Y HIGH IRON: Y N OTHER CONTAMINANTS: Y Ni M 0 V) .e -d , b r � N°%40�) Date .................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that............................................................................................. has permission to perform wiring in the building of................................:.................................................. at............................................................................... . North Andover, Mass. Fee..................... Lic. No.............. .......................................................... 4 Etec RicAL INSPECTOR Check Il WHITE: Applicant CANARY: Building Dept. PINK: Treasurer NO (f."nwaa& o f Mddadtudalb For Office Use On] (Rev. 11/99) �•- cc� cc77 Permit Number: � � 1JsParfman� v`}ira �arvicad Occupancy &Fee BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WORK TO BE PERFORATED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:00) PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: /- / - c l City or Town of:_ N , ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location: (Street & Number) Owner or Tenant: ��'�4 A-- f r\ \\ !� J� Owner's Address: A ?n 0O � 2 C S 7 7 /.3 ,0 % d /� 3 p 1 T Q% Is this permit in conjunction with a Building Permit? Yes ❑ No IY (Check Appropriate Box) Purpose of Building:,ZES',',7 G'..?n Utility Authorization #:h r� 3a Q Existing Service: /Uri Amps,ao / a, -4Q Volts Overhead 111- Underground.0 # of Meters I New ServiceQ.Q o Amps \c),o / -)Y t3 Volts Overhead 00-- Underground.❑ # of Meters:_ Number of Feeders and Ampacity: Location and Nature of Proposed Electrical Work:.0 Q(, t?n-a it Sc 'i2 j.,/c jF 4 deq11, 40JFa Tkn G Jcc,: No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Transformers Total KVA No. Of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool: Above ground ❑ In Ground ❑ # of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners Fire Alarms # of Zones # of Detection & Initiating Devices # of Sounding Devices: # of Self Contained Detection/Sounding Devices Local 0 Municipal Connection o Other o l"p. of SwitchesNo. of Gas Burners No. of Ranges a No. of Air Conditioners TOTAL TONS: No. of Waste Disposals Heat Pump Totals: Number: TONS: KW: Security Systems: No. of Devices or Equivalent No. of Dishwashers Space /Area Heating: KW Data Wiring, No. of Devices or Equivalent: No. of Dryers __ Heating Appliances KW Telecommunications Wiring: No of Devices or Equivalent: No. of Water Heaters KW No. of Signs: # of Ballasts: OTHER; # of Hydro Massage Tubs No. of Motors Total HP INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Z;-' BOND ❑ OTHER ❑ Please specify: vc Estimated Value of Electrical Work $ 6,00 (When required by municipal policy) Work to Start: / -a4 - O l Inspections to be requested in accordan;e with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the Infor5ptigg on this applicat�n i e and complete. Firm Name: LA S! ?0,- E A- 4 C O A. J R 3 -� LIC. Licensee: Co tai=n_? i—' -i / 4!o Y Signature: LIC. # / 1910 P (If applicable, enter "exempt" in the license ber✓r - [� ?fit - Address: Ids- iv F,,,,QOSJ U SJ wOQv� +� i MA - Q11A D / Bus. Tel. #a-- 7 AA. Tel. #:2 fig - 3S� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I nereoy waive this requirement. I am the (check one) Owner ❑ OR Agent ❑ Signature of Owner/Agent: Telephone #, PER 13T FEE: S r 01 1 COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS \ EGISTERED MASTER ELECTRICIAN'\'` ISSUES THIS LICENSE TO ff : APPLIED RESOURCES INTEGRATE R ROBERT T KILROY 400 WASHINGTON ST BRAINTREE MA 02184-4729 16277 A. 07/31/01 75922.1 • COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS. AS A REG JOURNEYsMALICNSETLoECTRICIA ISSSROBERT T KILROY 14 MT VE�NON STREET , DEDHAM MA 02026-2803 ?9266 E 07/31/01 757714 ,� 9e {e„r�,ea„ureal// a�'llal.;ccc/c�:elf3 DEPARTMENT OF PUBLIC SAFETY License: SEC SYS COi (TRACTOR Number: SS CO 000588 Birthdate. 63 Expir3s. 11/03/2000 Tr. no: 192 Rests icted To: 00 ROBERT T KILROY 4C0 WASHINGTON S"r #308 B?AINTRE E, MA 02184 F.ct;rq (gmrniss:,n� s llu s' a ?zZ? q �p�►W co Q 4 3 oc w 03 ` Th, ? o N p awl i••�m.. 73- oo ` r �.�: ,.d�-�� V w O m d ...., ---4 Ol�� W , - iv N r 2 od q a�Wy� vg�o o �Q?;o �� �a a o ► W ►�. '� Q ►. �w �. 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