HomeMy WebLinkAboutMiscellaneous - 102 BRADFORD STREET 4/30/2018 (2)/0, o lid raC/, r�
6 74t -, � C I;-'
William F. Weld
Governor
Trudy Coxe
Secretary, EOEA
David B. Struhs
Commissioner
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
f3O�RD
�uN � 31996
Property Address: /0 Z 13-'4'0,r0e`-' S7 ti AtVZ)M I -Address of Owner:
Date of Inspection: j`'. //' �7(p (if different)
Name of Inspector: kICAA r -e ri sco e
Company Name, Address and Telephone Number:
6/ 61-7,r; so,c-) sr- '
CERTIFICATION STATEMENT 6,'ove /two
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:
!/asses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: IC3___ Date:
The System Inspector shall submit a copy of this 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 PASSES:
l/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 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 8/15/95) 1
One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500
i~f? Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: l0 ?—
Owner:
Owner: (f/Y)5
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 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 WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ Tho wsten- nay a septic tank and soil. absorption system and is within 100 feet to a surface v, -.-ter suppl•t e; tributa^, to
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.
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
cesspool.
(revised 8/15/95) 2
0
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /0 Z 13,, -A -d- - ,�c( .7
Owner: CroS S
Date of Inspection: 5"- // • 576
D] SYSTEM FAILS (continued):
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.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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 suppiy 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 8/15/95) 3
N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: Cry S S
Date of Inspection: .S,
Check if the following have been done:
Pumping information was requested of the owner, occupant, and 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.
_k'A-s built plans have been obtained and examined. Note if they are not available with N/A.
vThe facility or dwelling was inspected for signs of sewage back-up.
_�`The system does not receive non -sanitary or industrial waste flow
%he 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 or
��approximated by non -intrusive methods.
" The facility ov:ner tand occuPan.t`., if diffem^' frorr o�Nner) were provided with information on the proper maintenance of Sub-
surface Disposal System.
(revised 8/15/95)
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /6 Z 06,-A�/o� S T
Owner: C• -Os 5
Date of Inspection: S l/ • i 6
FLOW CONDITIONS
RESIDENTIAL:
Design flow: >;allons
Number of bedrooms:
Number of current Pesidents: 2.
Garbage grinder (yes or no):_/,et7
Laundry connected to system (yes or no): V65
Seasonal use (yes or no):"
Neater meter readings, if available:
Last date of occu an C CG>/'0/6.0
COMMERCIAUINDUSTRIAL:
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:
Last date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
PUMPING RECORDS and source of information:
GENERAL INFORMATION
3
System pumped as pan of inspection: (yes or no) lis`
If yes, volume pumped. 100 O gallons T ,
Reason for pumping. i"O-1
TYPE OF SYSTEM
___L,::,1eptic 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)
w i' /'pc O'l-c-f S
APPROXIMATE AGE of all components, date installed (if known) and source of information: 26 I/C41L G
Sewage odors detected when arriving at the site: (yes or no) 24�0
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: AO Z 61WPJ� S %
Owner: �►^CTSS
Date of Inspection: 57, // • 57 6
SEPTIC TANK:y�s
(locate on site plan)
Depth below grade: 2 f/�t
Material of construction: L-�Ccncrete _metal _FRP _other(explain)
Dimensions: /600
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
!!�� /CJS G . UOc
Comments: f'U/y!� d✓
(recommendation for pumping, condition of in el t and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:—A-0Xje
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thicknes .
Distance from top of scum to top of outlet tee or baffle:
rlc'` •vn i.c^. fq C'll'i?'. ter' o' naillf..
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 8;':5/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16Z
Owner: C/OS S
Date of Inspection: 3—, //, �6
TIGHT OR HOLDING TANK:Z0
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP _other(explain)
Dimensions:
Capacity: gallons
Design floe-: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: W05
(locate on site plan)
Depth of liquid level above outlet invert: (5
Comments:
(note if level and distributlu; : iE cq::a!, evidence or solid: carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_A)OA.)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 8/15/95) 7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /Q Z f3j/t�ji� S'i
Owner: C�--V �; S
Date of Inspection: r-11- 96
SOIL ABSORPTION SYSTEM (SAS):--yC`'S
(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:
1
leaching fields, number, dimensions: / Z C ?c So
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: lVC}/ve
(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 inspecti
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: -A4 Ale
(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 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/SYSTEM INFORMATION (continued)
Property Address: /b Z /3�Afro /CX S7—
Owner: �'v U 5 5
Date of Inspection: S–,1�, 96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' -
1)
DEPTH TO GROUNDWATER
Depth to groundwater: 3 feet
method of determination or approximation:
(revised 6/15/95) 9
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74-5 Lot 15,E Bradford St.
6LL) Scott Realty Trust
'92-
APPLICATION
02APPLICATION FOR SEWAGE DISPOSAL INSTALLATION (/ 4
12' HEALTH DEPARTMENT - NORTH ANDOVER, MASS. /k/
62
.•:
HH `
I hereby make application for a perdhit for a sewage disposal installation at
Lot f5 Bradford St. . I will install this system in ac-
cordance with all the laws of the Com onwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 29o. I will install a con-
crete septic tank of 1000 in size. A manhole (s) permitting easy cleaning
will be provided with removable 7over (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 200 lineal (square) feet of effective absorption area.
The pipes will be laid on a'6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until annroved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit Plot Plans must be submitted with application.
1000 sq ft
DATE 5119/69 �C��� •%' .
VSignature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE 5/19/69
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
..... ?--* -30
Percolation Test 17 Minutes Soil: Clay
Garbage Grinder
t
Signatur Inspectike e
/ r
0
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
t
1. NAMEC C% /L5,4- T% ,TOL/ c / DATE
2. ADDRESS LOT NO. ��� TEL. J b ,j X17,/
3. NO. OF BEDROOMS j� DEN YES NO__,L_
4. GARBAGE GRINDER YES NO X
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF ZOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
r . ?-A
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
NAME OF APPLICAN
LOCATION
SEWAGE DISPOSAL
DAT E S7/
BUILDING: Dwelling x( Other
SYSTEM: New Repair
GENERAL DESCRIPTION OF LAND
SUBSOIL: Clay_�D _ avel Sand
PERCOLATION TEST j'� minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK -6 -&-0 gallon capacity.
LEACH FIELD --?,&0 lineal feet of drain pipe.
William J. D is oll, Engineer
Board of Heal
G"7 N
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BAY STATE ADJUSTMENT SERVICE
83 Pine Street, Suite 107, Peabody, Mass. 01960
Telephone Numbers
(508)535-3334
• (800)865-2206
FAX (508) 535-7106
Town Fire Department
Building Commissioner
Town of North Andover
Town Hall
North Andover, MA 01845
Re: Insured: Benjamin & Michelle Cross
Property Address: 102 Bradford Street
North Andover, MA 01845
Policy No.: HMA2016636
File No.: 6 -857 -ICE
Board of Selectmen
Town of North Andover
Town Hall
North Andover,MA 01845
Company: Patrons Mutual Fire Insurance Co.
Date of Loss: 3/8/96
Type of Loss: ICE
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Massachusetts General Law, Chapter 143, Section 6
to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is
appropriate, please direct it to the attention of the writer and include a reference to the captioned
insured, location, policy number, date of loss and file number.
Paul R. Nestor, Jr.
General Adjuster
On this date, I caused copies of this notice to be sent to the persons named above, at the addresses
indicated by first class mail.
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