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Home My WebLink AboutMiscellaneous - 103 FULLER ROAD 4/30/2018 (2)Locationy t'�'�-- C' c No. f Check 42 , �Pl Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 36 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector `J A� Sys�e% 4o -PROPOSAL 20161. 210 Main Street North Reading, Massachusetts 01864 Phone: 1.978.664.5023 www.royalairsystem.com NAME: Mr. & Mrs. Keyo PHONE: 978-258-0909 DATE: ADDRESS: 103 Fuller Rd. OTHER: 4/7/2016 TOWN: North Andover, MA 01845 E-MAIL Pg. 1/1 CM We hereby submit specifications and solutions for: We propose to move the existing air handler over to a new location to accommodate the framing work being done. We will connect to existing electrical and drain, modifications included. Any modifications to existing supply and return to accommodate the new system. We will replace the 3 runs that are currently flex duct and install hard ducts. We will add to the existing refrigerant piping to reach new location. Any additional wiring needed. All electrical wiring to reconnect system by Royal Air Systems, Inc electrician. We will install a new 5" media air cleaner. All permits and inspections. Complete commissioning and testing. System Description RATED EFF.' TOTAL COST: = MONTHLY: Indoor Move existing air handler and replace flex duct with hard pipe Outdoor Accessories Aprilaire media air cleaner $2,500.00 Accessotbs Indoor 2 Outdoprr Accessories Accessories Indoor 3 Outdoor Accessories Accessories Guarantee and warranty information: This installation includes at least a 10 year compressor warranty and a 10 year coil and functional parts warranty on the air conditioner/ heat pump. A 100% performance guarantee on all work performed. A one year service contact on all new products. ,. *Financing available with your approved credit. We propose hereby to furnish material and labor— complete in accordance with the above specifications, we accept option # for the sum of: $ X initial Payment to be as follows: ❑ Financing ❑ upon completion per Cassie All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. Title to the equipment to remain with Royal Air Systems, Inc. until the final payment is made. All agreements contingent upon strikes, accidents, or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our worker is fully covered by Worker's Compensation Insurance. Work site must be available for inspectional services after the installation is completed. Acceptance of proposal: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. This Proposal may be withdrawn if not accepted within 15 days from the above date. J X X o !'FY � /ldi111' Customer Acceptance Signature DATE Royal Air Systems, Inc. Authorization Signature Date 41,11,9032jolow"awgram �9 QI SHEEN MTA`L WOiKERS - ISSUES THE. FOLLOWII`i I>CENSE AS?'A MASTER- UNRESTRICTED` ROY111 AIR SYSTEMS INC ARTHOR A P> G#I<E7'T � ROYAL Alfa SYSTEMS;ING .. 210.- MkI N ::ST: {#F iHxREA.DINO �A 01861+ ',<O4/z8j,lb 1016 a 193352 Please visit our web site at http://www.mass.gov/dpi/boards/SM ARTHUR A. PICKETT ROYAL AIR SYSTEMS INC (SM) 210 MAIN ST NORTH READING, MA 018&4 Fold, Then Detach Along All Perforations :COMMONWEALTH OF MASSACHUSETTS � e s •e9 BOARD OF SHEET METXL WORIfil; R5 ISSUES THE FOLLOWING LICENSE: AS A z '` BUSINESS a ARTHUR A. PICKETT z ROl'kL A1R SYSTEIVIS'INC z 210 MAIN ST2EEi + Z NORTH READING, MA 01$64 � ..1894 J 14 07/2s/z01 . ,. ROYAL -6 OP ID: CA ACORD CERTIFICATE OF LIABILITY INSURANCE DA 09/29/2015TE Y) 09/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Chase & Lunt LLC 65 Parker Street CONTACT NAME: Michael C. Howlett PHCNNo Ext • 978-462-4434 Fn//� No): 978-465-6204 Newburypport, MA 01950 Michael C. Howlett E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC p 09/28/2016 INSURER A; Merchants Insurance Group pREMI8ESEa occurrence I $ 50,00 INSURED Royal Air Sytems Arthur Pickett INSURER B: Atlantic Charter Ins Co PERSONAL & ADV INJURY $ 1,000,00 210 Main Street INSURER C : INSURER D: North Reading, MA 01864 INSURER E : AUTOMOBILE X INSURER F : COVERAGES CERTIFICATE NUMBER: RFVISION NUMBFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEOkDDL NS Evidence of Coverage POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FXI OCCUR X Business Owners CMP9155060 09/28/2015 09/28/2016 EACH OCCURRENCE $ 1,000,00 pREMI8ESEa occurrence I $ 50,00 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY F JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,00 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS HIRED AUTOS X NON -OWNED MCA0000121 09/28/2015 09/28/2016 EO ao1_N_E INGLE LIMIT $ 1,000,00 BODILY INJURY (Par person) $ BODILY INJURY (Per accident) $ Per accident)TY E $ Inc. A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUP9147830 09/28/2016 09/28/2016 EACH OCCURRENCE $ 1,000,00 AGGREGATE $ DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe unOFder DESCRIPTION OPERATIONS below N / A WCIOOI10902 10/10/2015 10/10/2016 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,00 .. E.L. DISEASE - EA EMPLOYEE $ 1,000,00 - -- E.L. DISEASE - POLICY LIMIT 1 $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CFRTIFICATF NO[ nFR t%AKIP=l 1 ATIAtU ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary / 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover City/Town MA 01845' State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Ma State SI15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther valuation by the Local Approving Authority 5/13/201C In a or's Signatu a Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover MA 01845 5/13/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 A Owner information is required for every page. t5ins • 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson owners Name North Andover MA 01845 5/13/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover MA 01845 5/13/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/ day flow 15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Owner information is required for every page. napetry maaress Lawrence Nelson Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 5/13/2010 Date of Inspection Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no ether failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5 103 Fuller Road Owner information is required for every page. rropeny Haaress Lawrence Nelson owners Name North Andover MA 01845 5/13/2010 Cityrrown State Zip Code Date of Inspection G. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedroomsdesi n : 4 4 ( 9) Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Owner information is required for every page. Property Address Lawrence Nelson owners Name North Andover Citylrown D. System Information Description: Number of current residents: Does residence have a garbage grinder? AAA 01845 5/13/2010 Zip Code Date of Inspection Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: 2 ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ® Yes ❑ No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Owner information is required for every page. Property Address Lawrence Nelson owners Name North Andover MA 01845 5/13/2010 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped 2009, owner 1500 gallons Measured tank Inspect tank & tees ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner information is required for every page. t5ins • 09/08 Uwner's Name North Andover MA 01845 5/13/2010 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: House built 1980, owner Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron thru wall 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 2" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M yv0`'103 Fuller Road t5ins • 09/08 D. System Information (cont.) 5/13/2010 Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ED 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: Date Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 t-ropeny Adoress Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 every page. Citylrown State Zip Code t5ins • 09/08 D. System Information (cont.) 5/13/2010 Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ED 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: Date Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name information is North Andover required for MA 01845 5/13/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ,� 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name required for is North Andover required for MA 01845 5/13/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t5ins - 09/08 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , •''t 103 Fuller Road Owner information is required for every page. t5ins - 09/08 rroper[y Haaress Lawrence Nelson uwners Name North Andover MA 01845 5/13/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 40' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road 5/13/2010 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 14 of 17 rrupeny moaress Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 every page. di /Town State Zip Code 5/13/2010 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover City town D. System Information (cont.) MA 01845 State Zip Code 5/13/2010 Date of Inspection Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately 110 CIA S-?, D-.0p?c �c t3��rt t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Owner information is required for every page. t-roperty Aaaress Lawrence Nelson Owners Name North Andover MA 01845 5/13/2010 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 6 feet Please indicate all methods used to determine the high ground water elevation: /1 /1 Obtained from system design plans on record If checked, date of design plan reviewed: , 5/31/1980 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Info at B.O. H. ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts J Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name information is North Andover required for MA 01845 5/13/2010 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 17 of 17 Y Commonwealth of Massachusetts City/Town of System Pumping Record w Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1.. System Location: Left side of house, Right side of house, Left front of house Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Citylrowh State Zip Code 2. System Owner: Name Address (if different from location) uity/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ��y 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter resent? '� p ❑Yes ❑�-N'o If yes, was it cleaned? El Yes ❑ No 5. Condi ion of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company — 7. Location where contents were disposed: O �4 n Lowell Waste Water Of F5821 Vehicle License Number cS _ 1.L -r -/C' Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 n t' Summary Record Card generated on 4/27/2010 1:48:19 PM by Karen Hanlon Town of North Andover Tax Map # 210-065.0-0082-0000.0 Parcel Id 15307 103 FULLER ROAD NELSON, LAWRENCE 103 FULLER ROAD N. ANDOVER, MA 01845 Class 101 Single Family Size Total 1 Acres FY 2010 Property Type Page 1 1 Residential UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until NELSON, LAWRENCE Payor 103 FULLER ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17208.0 - 103 FULLER ROAD Last Billing Date 4/2/2010 3160286 03 Cycle 03 Active UB Services Maint. Account No. 3160286 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 60.80 /1 UB Meter Maintenance Account No. 3160286 Serial No Status Location Brand Type Size YTD Cons 32154173 a Active 00 b Badger w Water 0.63 0.633 229 Date Reading Code Consumption Posted Date Variance 3/5/2010 652 a Actual 16 4/14/2010 -40% 12/7/2009 636 a Actual 29 1/12/2010 -17% 9/3/2009 607 a Actual 34 10/15/2009 -13% 6/3/2009 573 a Actual 36 7/20/2009 154% 3/10/2009 537 a Actual 16 4/29/2009 -31% 12/4/2008 521 a Actual 22 1/20/2009 -62% 9/4/2008 499 a Actual 59 10/10/2008 240% 6/4/2008 440 a Actual 17 7/16/2008 7% Trouble Code:03 3/6/2008 423 a Actual 16 4/11/2008 -41% 12/6/2007 407 a Actual 25 1/22/2008 -70% 9/13/2007 382 a Actual 91 10/12/2007 287% 6/12/2007 291 a Actual 24 7/20/2007 48% 3/9/2007 267 a Actual 16 4/16/2007 9% 12/5/2006 251 a Actual 14 1/19/2007 -75% 9/6/2006 237 a Actual 53 10/20/2006 257% 6/12/2006 184 a Actual 15 7/10/2006 -1% 3/17/2006 169 a Actual 16 4/17/2006 -53% 12/15/2005 153 a Actual 34 1/17/2006 -64% 9/14/2005 119 a Actual 102 10/14/2005 161% Trouble Code:03 6/7/2005 17 a Actual 17 7/15/2005 0% 4/25/2005 0 n New Meter 0 7/15/2005 0% 4/25/2005 1745 r Replacement -7 7/15/2005 -148% 3/5/2005 1752 m Manual estimate 25 4/5/2005 -3% MSG Commonwealth of Massachusetts' City/Town of System Pumping Record, Form 4 tH WD0\jSR N�_ooa'tMEN�- DEP has provided this form for useby local Boards of Heal be used, but the information must be substantially the same as that provided Pre.Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left RI ht front of house Left/ Right rear of house, Left/ right side of house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town 2. System Owner. state Trp Code Name Address (if different from location) City/Town ' State E% tzjp Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ s Cess ool ,., S/e tic�Tank P () l.� P El Tight Tank 4. '5. ❑ Other (describe): Effluent Tee Filter present? ❑ Yes No Condition Qf $yo 5\�cLk 6.. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loca ' re contents were disposed: Lowell Waste W, If yes, was it cleaned? ❑ Yes ❑ No: F5821 Vehicle License Number Date Q�3 �� C�� v\ t5fomu4.doc- 06/03 System Pumping Record • Page 1 of 1 = 5064 NORTh � GL ` 1. • s Town of North Andover sa'•=,,,,, .• HEALTH DEPARTMENT CHECK #: - DAT LOCATION: "le H/O NAME: CONTRACTOR NAME:�—�w-4 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ �❑�Tit1e,5 Inspector � `�1 Title 5 Report $ $ 3; P ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusettp Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary) 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover City/Town MA 01845 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Ma State SI15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther valuation by the Local Approving Authority 5/13/2010 In a or's Signatu a Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 09/08 Title 5 Oficial Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover MA 01845 5/13/2010 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 2 of 17 �M Owner information is required for every page. Commonwealth of Massachusetlts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover MA 01845 5/13/2010 City[Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 .�C\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 5/13/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name nform equine fo d for tiis requireNorth Andover MA 01845 5/13/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 i ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 5/13/2010 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins - 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Owner information is required for every page. Property Address Lawrence Nelson Owner's Name North Andover MA 01845 5/13/2010 Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ® Yes ❑ No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner information is required for every page. Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: MA 01845 State Zip Code General Information Date 5/13/2010 Date of Inspection Source of information: Pumped 2009, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 103 Fuller Road Property Address Lawrence Nelson Owner information is required for every page. Owner's Name North Andover Citylrown MA 01845 5/13/2010 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: House built 1980, owner Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4” Cast iron thru wall 3" PVC in house. no leaks visible ❑ Yes ® No Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x5'x4' Sludge depth: 2" ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) Septic Tank (cont.) 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 31" 2" 8" 12" 5/13/2010 Date of Inspection How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 09/08 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road 5/13/2010 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 17 Property Address Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 every page. City town State Zip Code 5/13/2010 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 103 Fuller Road Owner information is required for every page. Property Address Lawrence Nelson Owner's Name North Andover MA 01845 5/13/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 103 Fuller Road Property Address Lawrence Nelson Owner information is required for every page. Owner's Name North Andover MA 01845 5/13/2010 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 40' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner's Name North Andover MA 01845 5/13/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Fuller Road 5/13/2010 Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately A D- 43c,X A4, t = i5 'to" a - l 31 BAC) 1 '314.11 3 =1-411 1 t©u t5ins • 09108 Title 5 Cfficial Inspection Forth: Subsurface Sewage Disposal System • Page 15 of 17 Property Address Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code 5/13/2010 Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately A D- 43c,X A4, t = i5 'to" a - l 31 BAC) 1 '314.11 3 =1-411 1 t©u t5ins • 09108 Title 5 Cfficial Inspection Forth: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 5/13/2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 6 feet Please indicate all methods used to determine the high ground water elevation: /3 Obtained from system design plans on record If checked, date of design plan reviewed: 5/31/1980 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Info at B.O. H. ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 ' <CN Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 103 Fuller Road Property Address Lawrence Nelson Owner Owner's Name information is required for North Andover MA 01845 5/13/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist t5ins • 09/08 ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Tifle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 �LN Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address(03 Fu Roo�� 1 V City/Towh State Zip Code 2. System Owner: Name Address (if different from location) City/Town State Zip Code Sa— q -S-5-c� Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Other (describe): Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ©--f0 If yes, was it cleaned? ❑ Yes ❑ No 5. Condi ion of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: LAS. D j /-% Lowell Waste Water of t5form4.doc• 06/03 F5821 Vehicle License Number L r iv Date System Pumping Record • Page 1 of 1 4 103 FULLER ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Summary Record Card generated on 4/27/2010 1:48:19 PM by Karen Hanlon Page 1 ' Town of North Andover ' Last Billing Date 4/2/2010 Tax Map # 210-065.0-0082-0000.0 3160286 03 Cycle 03 Parcel Id 15307 Active 103 FULLER ROAD NELSON, LAWRENCE Account No. 3160286 103 FULLER ROAD N. ANDOVER, MA Service Code Rate 01845 Class 101 Single Family Property Type 1 Residential Size Total 1 Acres 1/ FY 2010 01 ALL METER SIZE UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until NELSON, LAWRENCE Payor 103 FULLER ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17208.0 - 103 FULLER ROAD Last Billing Date 4/2/2010 3160286 03 Cycle 03 Active UB Services Maint. Account No. 3160286 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 60.80 /1 UB Meter Maintenance Account No. 3160286 Serial No Status Location Brand Type Size YTD Cons 32154173 a Active 00 b Badger w Water 0.63 0.63 229 Date Reading Code Consumption Posted Date Variance 3/5/2010 652 a Actual 16 4/14/2010 -40% 12/7/2009 636 a Actual 29 1/12/2010 -17% 9/3/2009 607 a Actual 34 10/15/2009 -13% 6/3/2009 573 a Actual 36 7/20/2009 154% 3/10/2009 537 a Actual 16 4/29/2009 -31% 12/4/2008 521 a Actual 22 1/20/2009 -62% 9/4/2008 499 a Actual 59 10/10/2008 240% 6/4/2008 440 a Actual 17 7/16/2008 7% Trouble Code:03 3/6/2008 423 a Actual 16 4/11/2008 -41% 12/6/2007 407 a Actual 25 1/22/2008 -70% 9/13/2007 382 a Actual 91 10/12/2007 287% 6/12/2007 291 a Actual 24 7/20/2007 48% 3/9/2007 267 a Actual 16 4/16/2007 9% 12/5/2006 251 a Actual 14 1/19/2007 -75% 9/6/2006 237 a Actual 53 10/20/2006 257% 6/12/2006 184 a Actual 15 7/10/2006 -1% 3/17/2006 169 a Actual 16 4/17/2006 -53% 12/15/2005 153 a Actual 34 1/17/2006 -64% 9/14/2005 119 a Actual 102 10/14/2005 161% Trouble Code:03 6/7/2005 17 a Actual 17 7/15/2005 0% 4/25/2005 0 n New Meter 0 7/15/2005 0% 4/25/2005 1745 r Replacement -7 7/15/2005 -148% 3/5/2005 1752 m Manual estimate 25 4/5/2005 -3% MSG TOWN OF SYSTEM PUMPING RECORDi NOV 2 6 DATE: I I ` �-. SYSTEM OWNER & ADDRESS 60a -��[ (e -c SYSTEM LOCATION (example: left front of house) ft� �11'ovt`� o� wsf- DATE OF PUMPING: QUANTITY PUMPED : 0 D GALLONS CESSPOOL: NO YESSEPTIC TANK: NO YES 7NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste FORM U --LOT' RELEASE FORMr INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from- - Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****APPLICANT FILLS OUT THIS APPLICANT PHONE LOCATION: Assessors Map Number 0( 65 PARCEL Oado' SUBDIVISION STREET �u rim 2fD LOT (S) ST. NUMBER /0 3 USE ONLY **mak** ******* RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE. REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH C INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT R;=CEIVi=D BY BUILDING ii ISPECTOR DATE NEW ENGLAND ENGINEERING SERVICES INC December 16, 1997 North Andover Board of Health Town Hall Annex School Street North Andover, MA 01845 RE: TITLE V REPORT 103 Fuller Road. Enclosed is the Title V report for 103 Fuller Road, North Andover, MA. The system conditionally passes our inspection. If there are any questions please call me at my office, 686-1768. Yours truly, e Benj C. Osgood Jr., E.I.T. President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 WILLIAM! F WELD Govcmo: ARGEO PAUL CELLUCCI Lt. Governor C0Mj,j0N\VEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. AIA 02108 617-292-5560 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 10-5 /t'/L Q .-V Address of Owner: Dale of Inspection: /o6AMN 29 (If different) Name of Inspector: BE�T�. OSGOOD JR. ' I I am a DEP approved system inspector pursuant to Section 1S.340of Title 5 (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING StRVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA_ 01845 Telephothe Number: 508-686-1768 11 1 TRUDY CORE Sccrctm DAVID B. STRUHS Commissioner CERTIFICATION STATEI LENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: �PLasses �ondrtronall- Passes Needs Further (valuation By the Local Approving Authority Fails Inspector's Signature: Date: l Z O The Svstem !nspector shall su mit 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 repon 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 byyer, if applicable. and the approving authority I INSPECTION SUMMARY: Check A, B, C, or D4 AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure c: to::a 2s defined in 310 CNAR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: VSTOne 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 pus. Indicate yes, no. or not determined (Y. N. or ND1. Describe basis of determination in all instances: If -not determined'. explain why not. The septic tank is meal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance Uttached) indicating that the tank was insulted within r to the date ion; or the septic-unk, whether or not metal, is cracked, structurally unsou shows substantial Infiltration r exfiltation, r tank failure is imminent. The system will pus inspection if the existing se(,—cupnk is re ac with a confotmtng rc tank as approved by the Board of Health. f—i—d 04nai971 P.C. I .,i 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address: 1&3 r )Ile.,, nn /` 66, ti , .,A,,) ex - Owner: uhe ' 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;. Describe observations: 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 replaces cbstruction is removed I + I I Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: + Conditions exist which reouire further evaluation by the Board of Health in order to determine i(the system.is failing to protect the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH gETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER + WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON ENT: I Cesspool or pra-v Is within 50 feet of a surface water Cesspool or pr,.-%• 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: I The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a suriace 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 SO feet of a private water supply well. r The system has a septic tank and soil absorption system and the SAS is less than 100 feet but SO 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 S ppm. Method used to determine distance (approximation not valid). 3) OTHER (r.vi•.d 04/]5/97) 1.y. 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 103 Owner: v ie Date of Inspection: �J7b111- `t DJ SYSTEM FAILS: You must indicate either -Yes- or -No- as to each of the following: I have determined that the system violates one or more of the f611owing 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. 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 watersdue to an overloaded or clogged SAS or cesspool l— Static I4gdid level in the distribution box above outlet invert due to an overloa0ed 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. i Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tomes pumped ' Any portion of the Soil Absorption Svstem, cesspool or privy is below the high groundwater elevation An. ponion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a suriace water supply. Any portion of a cesspool or privy is within a Zone I of a public well. ) An-, portion of a cesspool or pri%y is within 50 feet of a private water supply well Any ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply Weil with no acceptable water quality analysis. If the well has been analyzed to be acceptable. anach copv of well water analysis for cohiorm bactgria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: I You must indicate either -Yes- or -No- as 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 If 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 04/15/17) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: 14>3 ,Ile t 12, f/- /}JbL)e1.. Owner: Lf- Ae- 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 pan of this inspection, V As built plans have been obtained and examined. Note d then ere not livailaWe 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 (low. The site was inspected for signs of breakout ' — All system components. excluding the Soil Absorption System, have been located on the site. i The septic tank manholets were uncovered, opened, and the interior of the septic tank was in{pected (or condition of baffles or tees. material of construction, dimensions, depth of liQuid, depth of sludge depth of scum. I l � %ces g6.,c el T: t/ 4 r -,w — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner tand occupants, if different irom owners were provided with information on the proper maintenance of Sqb-Surface Disposal System. Existing information. Ex.lPlan at B.O.H. i — Determined in the field (d any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/27) •Aq• 4 or 20 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM PART C SYSTEM INFORMATION Property Address: �eX /4 Owned �_�e f gc� (" Date of Inspection: / C: /2 '/'q -) FLOW CONDITIONS RESIDENTIAL: Design flow: e.p.dJbedroom for S.A.S Number of bedrooms: Number of current residents: ij Garbage gror.der (yes or no!:Z Laundry connected to system (yes or no): Seasonal use tyes or no):AL Water meter readings, if available (last two (1) year usage (gpd): _ Sump Pump (yes or. no): Last date of occupancy: C u/-/,eA7' I COMM ERCIAUINDUSTRIAL: Type of establishment: Design flow: �allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives or no)_ Non -sanitary waste discharged to the Title 5 system (yes or no)_ "later meter readings, if available Last date of o--cupane•: r a OTHER: (Describe! Last date of occupancy. I ` I ' GENERAL INFORMATION , PUMPING RECORDS and source of int ormat P� *� 12 e a n e- 17 -F..l— System pumped as part of inspection: (yes or no) ,6? I( yes, volume pumped: ttailoAS Reason (orpumping 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) VA Technology etc. Copy of up to date contract? Ocher I APPROXIMATE AGE of all components, date installed (if known) aril source of information: Sewage odors detected when arriving at the site: (yes or no) N tr.ri..d 04/25/97) •.p. s or 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: IO�' j�✓%�F.t �cY J, AV, ff., /fes Owner. (}. &C(z Dale of Inspection: / '% BUILDING SEWER: ` (Locate on site plan) 1 Depth below grade: Material of construction: cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction Ione D)ameter Y AV Comments: (condition of)pinks, venting. evidence of leakage, e} ) SEPTIC TANK:_ I (locate on site plant Depth below grade:(• Material of construction: Zconcrele _metal _Fiberglas{ _Polyethylene _other(explatn) If tank is metal. list age _ Is age coniumed by Cenificate of Compliance _ (Yes/Nol Dimensions: JL5 -06 Sludge depth: i / Distance from top of sludge to bottom of outlet tee or baiflre: iGirr G Z )(0 // S//r� �J Scum thickness: %c -s 1. o_ -tz-,��,, Distance from top of scum to top of outlet tee or baffle. Distance from bosom of scum to bottom of outlet tee or baiile: How dimensions Mere determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stru4tural integnnrity,evidence of lea/ ge, etc.) i -e ,a I/ 15 //a 1�n lea, 1'_j GREASE TRAP:_ (locate on site plant 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 ice of 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.) (revi■.d 04/25/97) rag- 6 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:fTj j �J�/�j / -t/`�� Owner: Date of Inspection: x"c TIGHT OR HOLDING TANK: i7ank 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 floc . gallonJda. I Alarm level Alarm in working Jrder _ Yes. _ No I Date of previous pumping: Comments - (condition of inlet tee, condition of alarm an'd float switches, etc.) ' DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet inven: U Comments: ' ' (note ii level and distribution is equal• evidence of solids carryoler, evidence of leakage into or out of box, etc.)_ I i- - PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No) _ Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) tr. i..d 04/25/» i P.V. 7 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: !Uj T) V. Ar 0&� Owner: Date of Inspection: J?c r 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: �t. i leaching trenches, number,length: leaching iields, number, dimensions:_ overflow cesspool, number: Alternative system: ' Name of Technology:' Comments: (note condition of soil, signs //Qf hydraulic failuLre, level of pondin , condition of vegetation, etc.) �r_ o &f I CESSPOOLS: _ (locate on site plan) Nymber and coniigurauon Depth4op of liquid to inlet inven: ' DRpth of solids layer: Depth of scum layer: Dimensions of cesspoo!: Materials of construction: I i Indication of groundwater: inflow (cesspool must be pumped as pan of inspectibn) ' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction - Depth of solids: Comments: (riote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (rrvisad 04/2s/f7) P.q• • of 10 Dimensions: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner J �lJ J7 A1Jc�C�( Date of Inspection: J vc-� a c L; /v/2 � y-7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (r.vip•d 04/75/971 P.V. f of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertv Address: Ile 2 Owner. Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: V"Obtained from Design Plans on record Observation of Site (Abunmg property observatiod hole, basement sump etc.) Determine it irom local conditions Check .!th !oca! 'Suerd of health I I I i —zChec� FEMA Maps i Check pumping records t Check local excavators, installers Use USGS Data Describe in •oSr own words hos.• you established the High Groundwater Ilevatron.t(Must be comple(ed) GJ e �' c, � o,�t 1.3-s � u ✓ i l V IZ> (. y !� 4 C." r -J' .S �'L J...� may. < :'� �.r`_: ' b L (. !f� �j P' CC� ..✓ (r.vi..d o4/7S/97) P.y. 10 or 10 TIGER ENVIRONMENTAL . ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 5 !c`�Q 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION nwnPr'.s Name- / 1107'Ny e J111V6 ROC -4 Property Address: ffA Date of Inspection: Name of Inspector: a/ANAI/ lq Address of Owner (if different): Company Name: Mailing Address: - __j I am a DEP approved system inspector pursuant Telephone Number: to Section 15.340 of Title 5 (310 CMR 15.000) ❑ Voluntary Assessment (Not Reported) CERTIFICATION STATEMENT: Name 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 X Conditionally Passes Needs Further Evaluation By The Local Approving Authority Fails Q�} Inspector's Signature: Date: /— zi— r U 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: 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. �_�"" Comments: �.. 6-a4o� _ of _D/STni607-70n/ f�k A�62Z Mitjog 77 1`1'112 W17 -,f{ f D/�tt/uL C 1E�/T Hn� N�1 Co✓o2 ,cs l4EQ01RkZ_ B] SYSTEM CONDITIONALLY PASSES: X 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. N 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 conforming septic tank as approved by the Board of Health. 1of10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 143 f a -A&, /U• 4100 ✓�9 YA Owner: A" 04 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): Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is le-v-er-fop6sed I'S�wieejt ' 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 3) OTHER: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic com- pounds 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). 2 of 10 TIGER ENVIRONMENTAL • ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: A8 �U,69 F�2) 1 Al. AA&)0VK—, PYA Owner: Roc—e— Date of Inspection: /— 2g. D] SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: /VCS 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. Yes No Na Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. A/0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. �6 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ISD Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. AID Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped IVO Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Ald 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 1 of a public well. �a 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 n 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: A/ 1/4 You must indicate either "Yes" or 'No' as 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 suface 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. 3 of 10 M TIGER ENVIRONMENTAL f ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /0_� j0VI yiR b 1 Al. 4n4a ✓M, MA Rock Owner: n Date of Inspection: �-' 29_ M 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 th owner occupant, or Board of Health. YNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /� As built plans have been obtained and examined. Note if they are not available with N/A &,e_> 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. yAll 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. . Existing information Ex. Plan at B.O.H. 1 0 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)] 4 of 10 r Property Owner: Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION /03 t ou.R a Al- A-00 05 1 IVA FLOW CONDITIONS RESIDENTIAL:/ ,A Design flow: 0414 /IVg.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: 2 -- Garbage grinder: (yes or no) A/0 Laundry connected to system: (Yes or no) — Seasonal use: (yes or no) 1V4 Water meter readings, if available [last two (2) year usage (gpd)]: / /Z96 127 f 2 6� /2 97 J 1-7 Sump Pump (yes NO I/N,7,5 Alar' G+tlAl Bch— S f1r-i IISSUM�,J , Last date of occupancy: GJR�niTL /©D Gt/- F?: COMMERCIAL/INDUSTRIAL: 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 Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: PUMPING RECORDS and source of informatior System pumped as part of inspection If yes, volume pumped: Reason for pumping: (yes or no) GENERAL INFORMATION (yes or no) _ gallons TYPE OF SYSTEM: X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Alo Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other (explain) APPROXIMATE AGE of all components, date installed (if known) and soupe of information: ALL c0AV)4W&MM 1W_&_- _ a2167AIlk f is y/ZS 1-6?P— CRI&A& BL Sewage odors detected when arriving at the site: (yes or no) 4/0 5 of 10 . ;, TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ld3 Oa/ AJ.,IANVa, Owner: ROGk Date of Inspection: I _t A BUILDING SEWER: (Loc to on site plan) Depth below grade: //�\// 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 plan) Depth below grade: /Z" Material of construction: 7t concrete metal Fiberglass Polyethylene other (explain) If tank is metal, li t age Is age confirmed by Certificate of Compliance? (yes/no) Dimensions:± -All x 11=6 x ' -,Deep ( 1500 cwqu. ) Sludge depth: NONE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: NONE 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: MEASU21Z> iNTHdo2 OF Tf1N4_ 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.) GREASE TRAP: NO (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: (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.) 6 of 10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /08 t"1/GG,64 Q Al. "06C , YA Owner: OC. Date of Inspection: /— z9— TIGHT OR HOLDING TANK: fVf7 (Tank must be pumped prior to, or at time, of inspection) (Locate on site plan) �. Depth below grade: i Material of construction: concrete metal Fiberglass Polyethylene Dimensions: Capacity: gallons Design flow: gallons/day 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:G(1/»l DL7T (Locate on site plan) Depth of liquid level above outlet invert: ✓EA/ other (explain) Comments: (note if level and distribution is equal evidence of solids carry overtevidence ofaeakage into or,.out of bbx,'etc.) T- rztoR aF -6DX- Me&>S MIA469 Ri,e- wird CEi0Er►rf— Anima AIC -Al 42ZV 9- ' &Y- f5 L&/EL W177� 6+A DSMi,6077-41/ ' ND je�Vlj- vCE OAF SUu z�s C2 b1/�2 . PUMP CHAMBER: / "O (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.) 7 of 10 Property Address: Owner: h Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) /03 id-ULOQ IA SOIL ABSORPTION SYSTEM (SAS): �EZ (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 Di .3'Z% 6 � Leaching pits, number: Leaching chambers, number: 6y rLyAtAl Leaching galleries, number: /�LAS� Leaching trenches, number, length: r Leaching fields, number, dimensions: {FEZ 72s-6ocr ?rc�1 8y Overflow cesspool, number: NK C. ^ 6GAj� k�1 Alternative system: c'� Name of Technology: 'q -ZZ- e0 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ,:�iL AkmJ.AQ, -f iC � e,�t/�r�"cw Z,AS -7-D24 _�V - Na Sr.* S i CESSPOOLS: (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) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /40 (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.) 8of10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 .A. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /8 t^'uU-6k %iAl- *Jo%I AIA Owner: ROGK- Date of Inspection: 1-29- ffl SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks Locate all wells within 100' (Locate where public water supply comes into house) WETLAr D AREA REARS= 3S; b„ GAR AC-jE{ 4 ' ;► . .. . . . . . . . . . . . . . . . . . . . . I . . . . I . I . I . . I . . . . . . . . . . ..... . . . A7� 23' 2.a52� . . D. .�. . . . . . . . . . . . . . . . E 1500 evUcS S00n(- I I. . . . . A . . . . :, . . . . I . . . . . I . . . . . . . . . . . . . ,.3 01!r4- tD 26'; fcahl SIDE . I j AREA . . . . . . , . .r ._..J. . . . . . LTS . . . . . . . . . . . . . . . . . OW ,j SRF TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16-S raua /RD • z AJ. 4A60 146k , AM n � Owner: t'SoG„L' Date of Inspection: — .2 DEPTH TO GROUNDWATER: Depth to groundwater: -4+ feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump, etc.) Determine it from local conditions Check with local Board of Health Check FEMA maps X Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed)- a6,S6R✓A7 ; 0tZ& JkOM Z195- 1'0'VMj0)A1 ��6' q' d- - 9� 6 Y R�� Mev , �y��r. MA S#m%�s ND 1_64c fii Eur fi11n4e&q61G . ExWA7-10d ACE ACJ/165_Arr -7 :Z)%s77?4,31sric�/ 60x A7Vb 2 /r-- Ae t D,Xl ALWV r W l r7l METAL AUb / /C),&nlj�- AV AI bl-7i0A/,4L 1-2- �- hl.b wh-rE,- LEy6t VISIBcIO, 4S WJ�RA5:iV - Et:E VATrA/p The intent of 310 CMR 15.302 is to provide reasonable guidelines for the inspection of existing systems in as non -intrusive a manner as is possible to avoid damage to the system and any unnecessary disturbance of the surrounding soil area which is related to the treatment process. The inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the new owner. The inspection criteria are intended to allow for timely inspection to avoid undue delay in the transfer of property. I understand that this report does not constitute a warranty or guarantee of future operation. Client or Representative Date 10 of 10 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. til Commonwealth of Massach City/Town of System Pumping Record Form 4 OCT 2 3 2007 TOWN OF NORTH AN _NT FIEALT�t 0VARThIENJE T DEP has provided this form for use by local Boards of 1-166Iffi: Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System oca�t-i�on: Address V `S— v v `-4' !' City/Town State 4 Zip Code 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date 0 e A E: �- ,, A% State Zi Code Telephone Number 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes E I'�o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Kl©� �C L'-O�a'C 6. System Pumped ByT�s> �a� f. Name Vehicle License Number Company 7. Location re contents were sposed: Date t5fonn4.doc- 06/03 System Pumping Record - Page 1 of 1 TD Q L o CccZ o Q 1-> w -j o 5 �- LLJ � >� Q o �Q� LL mui W ,Q Q w wLL �� r< o Z � o OC) 00 I Q 6 V ' Z U (n ]C (11< 00 Q N Cfl _j n Q � w I C� �-- M w � a Z z < oo � ° Q Q Ci U w � �Qcr n- --1 CL C I oz 107 1%N z Z M 0 w ao 1 , O Cr w 0 > a- Ow p0 Z V) uiQ J xrn O M Z- W lad I ozoZ 0 F- Y Q. 01) 22'U-03 Q 0rl() > Q z w� `r w X Z z = 0 w j; Li t~= N o W o cn U- > _ W 3: w .. W O � Q w p z u cn a a_ J ` w o 1• Lf) CL � I 1%N (\j Z M w ao 1 , O Cr w 0 > a- Ow p0 Z 0J mw x xrn O M u W lad I ozoZ Z Z Q. 01) 22'U-03 0rl() z wZ I XII W LL � L. N N ! o �' ! Ow J w I� ANVi *-lV9 0051 = V 006 Z M w ao f 0 Lt WW o � M Ow p0 Z 7 mw x xrn O M 0M CO 7 m > ; I ozoZ 000(,Q �� OD ro rr) _ O0 } Z w Qi Z J MF- ►- w J �-- O Z D w O o> z z =z Q 00 J 'Q z 0 U) N � Z � U M W J = w m r-< z cn Z < > Z A N 00 r N ":U D O uc m 0 M--- z O 17 - r 8 — D zO 0 D w Z z <C 00 m0 ZD Z N- O uc m rr -- C z O (D r m 0 c cD m -4 _ -1 OD m (JD v m m Z 00 O 00 NO lD cD (.61D (D000 W I — p 0 �x w ox m aj .__ 00 m0 ZD Z N- <� rr -- r' W 0 m ;'J -n w (D --j --t uj cD O OD m (JD v m 1500 GAL. TANK O l N N OLnZ o x Zlm < z D tI) �VDv -u wm(D m �rn Zr. Don O m rr, CO v m D D < Z PO � oo Ott r00 — rrn m � Oz ? .. m r t- y _ m N ? TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: g -2:e -o) (example: left front of house) CIJA-- -46,4± 6-� 09252001 DATE OF PUMPING: X24 -61 QUANTITY PUMPED `?`' - GALLONS CESSPOOL: NO YYES SEPTIC TANK: NO YESLz NATURE OF SERVICE: ROUTINE ZEMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: ___( )-. Z/:" 'S, Z> r Board of Health North An�verjxass* UV—M DATE 1 / FAIL OK 6 VZMC MTEK INsrALLATICK CHECK LIST Reaamst LOT 7XCAVATI i�O�KFAIL 1. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PVC Pipe 4. Septic Tank a. -Tees -_Length & To Clean Oat Covers b. Cement Pipe to Tank - on Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6.. Leach Field or Trench a. Dimensions b, Stone Depth ce Capped Inds d. Clem DoubleWashedStone' 7. Leach Pit a.7eh Pit. ions 1) Sto Depth Pads c. SO ash Pads d T s T s 6 ��r 9: mmt pipe to pit Both Sides, f. Clem Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted— a. Lot Location.. b* Dimensions of System c. Location with Regar&to Pere Test d. Elevations e: Water Table -vi -La xnaover,t1aBs ti DATE deds title V 'eg 2.5 g6 KM SUBSURFACE DISPOSAL DESIGN CHDCK LIST DISAPPROPM Reasons MA DATE The submitted plan must show as a minimums ~_ a) the lot to be se rved-areaidimensions lot b location and log deep observation ho istan a to location and results percolation tests -distance tiess design calculations & calculations showing required leaching aZ'@g f existin system -including reserve area �8) location and Proposed contours ducal � wet areas Vithin .100+ of se a rimer -check wetlands mapping disposal system or surface and subsurface drains within 100+ systemor disclaimer of sewage disposal >i) location any drainage easements within + system or disclaimer_ g Board �i.1.es es of serge disposal 3) kao�a sources of Vater . system or disclaimer P1Y within 200+ of sas�ge disposal _ ka location of anY proPosed ,,,�. to s 1) location of water lines on +lfrom:Le from leaching facility ;)' location of benchmark pi`°psrty-10 from leaching facility 1) 11 drivew� >j garbage disposals. )- no PVC to be used in construction 1) Profile of system- of basement distribution box inlets and s plus Pipe, septic Tanks '�Bther elevations outlets, distribution field piping and maxim=�.ground water elevation in area s Plan est be prepared by a pi.otessional Eaginevage-disposal-system Professional authorized ' ®er or other �law to Prepare such plans S- tic Tanks A capac t es -7 of flow, �- access, pumping s t ' table' teess depth of tees$ i.b) cleanout Vic) 101 from cellar wall or in -ground sutmm a Imb d) 25+ from subsurface drains g Pool - 10.2.Distribution Boxes ' 10.4� MP °Pe greeter 0.08 Watershed Septic System servicing Report 7 V ' � y Date: Homeowner:_"-� _ Pumper Street _IDS Address: Phone PIC l Phone F '1�1_ two Nature of Service: Routine/ Emergency Observations: Good Condition 6 Full to Cover Q Baffles in Place LeachEield Runback J Excessive Solids JUO Heavy Grease Roots A)O Other (Explain) Description of Work*, J Comments: TIGER ENVIRONMENTAL ENGINEERING 1 -800 -62 -TIGER (1-800-628-4437) TIGER HOME INSPECTION PAID O BALANCE DUE O INVOICED O VOLUNTARY ASSESSMENT Preliminary Title 5 Statement 7s 2 ZW,s _Dr6- �90 To Whom It May Concern: R15: /G, j -ju 4 - A,l AIDO ,6p l A114 034oezr--� This page does not constitute the complete results of the Title 5 Inspection. It is, however, intended to give you preliminary information. The completed Title 5 Report will be forwarded to you and the Local Board of Health. Your local Board of Health, once they review the complete Title 5 report, will inform you if any repairs or upgrades are required. All repairs or upgrades must be approved by the local Board of Health. This Statement is not a Title 5 Certification. These results may change upon review. I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommenda- tions regarding upgrade, maintenance and repair are consistent wi my trainin and experience in the proper function and maintenance of on-site sewage disposal system. l PRELIMINARY RESULTS ; IA7i I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system FAILS to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determiination is provided in the FAILURE CRITERIA section of this form. Failure Criteria: Backup of sewage into facility. _ Discharge or ponding of effluent to the surface of the ground or surface water. Static liquid level in the distribution box above outlet invert. Liquid depth in cesspool < 6" below invert or available volume < 1/2 day flow or more. _ Has required pumping 4 times or more in the last year. _ Septic tank is metal. Cracked. Structurally unsound. Substantial infiltration. Substantial exfiltration. Tank failure imminent. If any portion of the SAS, cesspool or privy are as follows: _ Below the high seasonal ground water elevation. Within 50 feet of any surface water. _ Within 100 feet of a surface, water supply or tributary tp a surface water supply. (Reservoir) _ Within a Zone 1 of a public well as defined by Board of Health. Within 50 feet of a bordering vegetated wetland or salt marsh. (Cesspools and privies only, not SAS). Within 50 feet of a private water supply well. Less than 100 feet but greater than 10 feet from a private water supply well with no acceptable water quality analysis. X SYSTEM CONDITIONALLY PASSES ZK One or more system components need to be replaced orepaire The system, upon com letion of the replacement or repair, passes inspection. VAI INSPECTION IS INCOMPLETE d46FR/O,e i�rn1 �/y� � � 9W itis�rz�v Now" b,,6,VevL,1,e _ Further excavation required to complete inspection. _ Additional components need to. be located. Further consultation with Board of Health required. _ Additional information needed. 16 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (lwnar'c Nama / /f►'�a1 �7 �i JVAhG' 86 Property Address: /63 6L -CCP ROAD &'- 1 to Date of Inspection: Name of Inspector: /A jA11 Address of Owner (if different): Company Name: Mailing Address: I am a DEP approved system inspector pursuant Telephone Number: to Section 15.340 of Title 5 (310 CMR 15.000) ❑ Voluntary Assessment (Not Reported) CERTIFICATION STATEMENT: Name 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 X Conditionally Passes Needs Further Evaluation By The Local Approving Authority Fails Q Inspector's Signature: 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: 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. Comments: 67*24 ok OF _�r5rn,16 err i oAl &>C.. d0Z S M/AIOR 1�9,fti2 W I Thq /Zhlu.L C017EA 7— fhb A/aJ Co%7` L5 B] SYSTEM CONDITIONALLY PASSES: < One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. N 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 conforming septic tank as approved by the Board of Health. 1 of 10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16-3 Owner: 0 G!G Date of Inspection: /— 29-oY6 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): Describe observations: broken pipe(s) are replaced obstruction is removed /� distribution box is I�a�►sed Qep..Ai2� 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic com- pounds 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: 2 of 10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /03 iC�L46R '.% /v� T i�vu' i 6 A Owner: Rock Date of Inspection: /— D] SYSTEM FAILS: You ry�ust indicate either "Yes" or "No" as to each of the following: 6 1 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. Yes No A/0 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. /10 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. A(O Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. A10 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. NO Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped A10 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Q Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. IVO Any portion of a cesspool or privy is within a Zone 1 of a public well. /Va 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: Al You must indicate either "Yes" or No' as to each of the following: The following criteria apply to large systems in addition to the criteria above: Yes No 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 suface 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. 3 of 10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 5 Date of Inspection: /—.99— Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Y� Pumping information was provided by th owner occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. / The system does not receive non -sanitary or industrial waste flow. S The site was inspected for signs of breakout. YAll system components, excluding the Soil Absorption System, have been located on the site. yE5 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: The facility if different from information owner (and occupants, owner) were provided with on the proper maintenance of Sub -Surface Disposal System. Existing information Ex. Plan at B.O.H. /VQ 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)] . f 4 of 10 Property Owner: Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION %Q3 C Q IJ AOo�g, IYA FLOW CONDITIONS RESIDENTIAL: _Z_ 1A I C/t3tF Design flow: l xi4b /g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Z Garbage grinder: (yes or no) A10 Laundry connected to system: (yes or no) Seasonal use: (yes or no) NO 9 Water meter readings, if available [last two (2) year usage (gpd)]: / 9S /L 9G %Z% %�6 /Z % / 7 Sump Pump (yes or no): NObN;� ��—&1 V6V �t� fS✓M'WU Last date of occupancy: GcJRi��L X00 " /-7— COMMERCIAL/INDUSTRIAL: 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 System pumped as part of inspection If yes, volume pumped: _ Reason for pumping: — GENERAL INFORMATION (yes or no) A/,D _ gallons TYPE OF SYSTEM: X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy A/o Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other (explain) APPROXIMATE AGE ofal components, date installed (if known) and source of information: ALL Co ,�M 62167A14Z .t 49 %/2S Pip, Ca2/&Aok 0ZJA(T Sewage odors detected when arriving at the site: (yes or no) �/o 5 of 10 f Property Address: ' Owner: Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) BUILDING SEWER: (Locatfe on site plan) Depth below grade: fin// Material of construction: cast iron 40 PVC Distance from private water supply well or suction line: Diameter: Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (Locate on site plan) other (explain) Depth below grade: Material of construction: _CX concrete metal Fiberglass Polyethylene other (explain) If tank is metal, list age Is age co firmed by Ce �ficate of Compliance? (yes/no) Dimensions:± 4�- P' x l l' -b" x ' p 1500 C-A�s ) Sludge depth: ivoNE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: NONE 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: MEtisi12i"p iN-T—EPioic' of —r -,Am IL 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.) N0 Pum PI J - RE co"I+ '1 1 me Lg r P2EtA-S7- CoA (R ►'E' -F ANGL) OuTI.Er" CaSCReTir &fFFLe I . LA a V a_ !" V ETf i N f EP -I "'�ti i_ A PP�'--'r1 ISi 2A! LTUPA� Saurv'� LA T4 N16 G \i1-_iFN X 61= 1ZA 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: (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.) 6of10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -� SYSTEM INFORMATION (continued) Property Address: t'�tC-L /�� AA2�6 Owner: /So G Date of Inspection: t TIGHT OR HOLDING TANK: D (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 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: Gtlt (Locate on site plan) / Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal evidence of solids carry over, evidence of leakage into or out of box, etc.) - �►2co2 OF -D-6bk nfg-a>', I)IJA162 &39j7,,P— 1, //7W rAjtbP.AAictc._ fhyl z>S 2ely 7I 27b -7; . PUMP CHAMBER: VO (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.) ,� 7 of 10 Property Address: Owner: Ro Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 103 c.c i P-l� A"/ NV6T�, SOIL ABSORPTION SYtTEM (SAS): E� F (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: DATQ� 3'27 Leaching pits, number: Leaching chambers, number: '6Y Leaching galleries, number: Leaching trenches, number, length: �� Leaching fields, number, dimensions: 22' x ASS 02 -601q- f� �y Overflow cesspool, number: Alternative system: FP�v/C C. &C-Un(;t5 � Assoc. Name of Technology: B-ZZ-gLO Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: (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) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /� o (Locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 8 of 10 TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /'08 Fu L OZ fijb ,i /4,/- AA�)o ✓&' , ILIA Owner: 0C- - Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks Locate all wells within 100' (Locate where public water supply comes into house) . . . . . . . . . . . . . . . . . . WerLni AAREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . REAR 58 6" . . . . . . . . . . . . ......... ..... . . . . . . . . . ... . . . . . .�... . . . . S. .. .Sp E 1500 Grt;S .S00 -/7L = .A . .SIG. /2'' 6E�ov✓ . D vrL�T �[�, Si7; �8✓7 ion/ . . . � . . . . . . . . . . . ............................... ,1 9 of 10 Property Address: Owner: Ryc Date of Inspection: TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 1-S tr—z_1&&r_K AD)-, Al Vim iy- DEPTH TO GROUNDWATER: Depth to groundwater: '4+ feet Please indicate all the methods used to'determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site (Abutting property, observation hole, basement sump, etc.) Determine it from local conditions Check with local Board of Health Check FEMA maps X Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) QBscP v'A-rv�s ikm 41?--,,-PVmP;AI�T �o sE �' �2 - �� y RGoTEr Mil �� , IIA S� No GE rIFi E�� RVAA&gce_1' . EXCAIAZLO&I AtE Ali J/965 -1y-1 ' "�Z)1,S772r,9JT_t4J/ 1�,-,X h7Vb 2 r�&-r t��Lolic/ AL. yV6, 1Vr774 /JELL Ab AV A:0/7 l�� 2 r7eET AV -.Z!> Gc/ATEk (c.=DIEL 1/616LEF /5 /D T W�%ol�r.✓(T ELE 1/�Ly�/_ The intent of 310 CMR 15.302 is to provide reasonable guidelines for the inspection of existing systems in as non -intrusive a manner as is possible to avoid damage to the system and any unnecessary disturbance of the surrounding soil area which is related to the treatment process. The inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the new owner. The inspection criteria are intended to allow for timely inspection to avoid undue delay in the transfer of property. I understand that this report does not constitute a warranty or guarantee of future operation. Client or Representative Date J 10 of 10 Jan -29-98 04:05P North Andover Com. Dev. 508 688 95421., P_01 Tele{shone# Amor- Robert T. 130 Installers Name License# Company Address Tele{shone# Amor- Robert T. 130 290 Middleton Road 503 -X37 -546X Baldountas, Louis 137 Ra,nlx>w 131jilders -Its rNmitor Dn%e 5U8-459-913) Bateson, Todd 109 Rawson Enterprises I I I Argila Road 475-1474 Breen, Peter 106 Peter Breen Excavating 770 Boa -ford Street 687-7774 Buco, America 128 34 Taylor Street 508-688.0104 Busby, Philip Jr. 104 Busby Construction Co. 9 Pond Line 603-362-4650 Carr. Jolui 121 3.3 Oak Knoll Road 508-683-6791 Cavallaro, Alrred 122 470 S \lain Street 508-475-2466 62 I ,oCku cod l uric 12 East Dra,:w Road DeLueiu, Rocci 135 386 Merrimack Sheet DeVencenzo. Jolui 136 Stewart Septic System 47 Railroad Ave. 508-172-747[ Giird. Daniel 124 130A Appleton Street 508-686-7653 Gibson, Alexander 113 A.D. Gibson 47 Country Road 50X-175.7496 Hall, Bill 102 Hill Hall Inc. I Jolli-e Streel 689-371! Halligan_ JanwS 131 36 Spring Street i0�-777-5072 Henderson, George 116 l'. 1 [endersun Cu.. 1nC. 280 Chandler Road 686-5X15 Hatton. Arthur 129 107 Lovell Street 508-635-2627 hmis. Bob 107 B.L.I. Corp. 475 Boston Road 508-663-6006 P.O. Bos 413 7 Orchard Crossing MailIet. Alvin 3 Wescon DFi.•e Maker, Ron 132 1 'Ford :\va- tifi3-R'iO 41159 Maynard, Dave 119 32X S. Hain Street R•1cKee, Brian III ' David \ICKC'a @ Son 35 Dunbar Road 617-944-5940 Melvirt, Tim 133 292 Afiddlcscx Street / > 0 COL Morgan, Daniel 120 27 \lapse Ave. 50X-686-9496 12 Carlton Si NCCt Wednesday, March 19. 1997 _ Page 1 .42 . . I O • • •• Gv' • �:'•� ` •� • •: •��' ` 1'x•1 1 :• 1 •�•• ` •DI •• a' I IY.� '��'• 1'� `1 Y 1 •��• II'�Y Y I. 111 • UWY+cu fli E O N' o� � m z n Q C v 0 A O (D Q 0 D D 0 a � -� 0 a 0 h _ o a ate, a• _ rr c� v � y 1 7 � 1 3 rQi 3 p 'fl C � O m 0h rt 0 c � 3 O C la a rt a V) Ln 0 (D K (D > ai (D (D O CD fl.. -11 co Lo (D Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record Svstem Owner & Address: Andrea & Kevin Keyo 103 Fuller Rd °' North Andover, Ma 01845 SES Location of system: Front FTQWN QF Date of Pumping: September 14, 2011 k�AL fe Type of system: Septic Tank Gallons Pumped: 1250 gallons System pumped by: Service Pumping & Drain Co., Inc. S Hallberg Park North Reading, Ma License #: BHP -2011-0413,0412,0411,0410,0409,0408 Contents transferred to: Greater Lawrence Sanitary District Date: September 14 2011 Pumping Technician: CH This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes