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Board of Health
North An ver M"s•
v�dc/ icJs/��7o�✓
01
Y
BEPY'IC SISTM
INSTALLATICK CHECK LISP
ILL LX" iitVVX"R '
easnnsi � ti7 �
n v
q Vev
LOT j &�reo 6K e- DtL,,
A
1. Distance Tot
a. wetlands DOv\e-
b. Drains
C. Well
2. Nater Line Location
V_
3.
No
PPC Pipe
C;D
•
tic Tank -
a. -Tess
--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 Anoints
c.
No Back Flow
6.
Leach Field or Trench
a.
Dimensions
b.
Stone Depth
c.
Capped lads
d.
Clean Double Washed Stone`
7.
Leach Pits
a.
Dimqnsions
b.
Sto Depth
c.
Splash
d.
Teas
e.
Cement P e Pit - Both Sides
f.
Clean ubYe hod Stone
8.
No
Garbage Disposal
9. -Final Grading Inspection Ttt-L: T°
10.
10. Barricading Covered system
11. As Built Submitted
a. Lot Location .
b. Dimensions of System
C. Location with Regard -to Perc Test
d. Elevations
e; Water Table
FAIL
L"___I
I OK
rT ` iit'1'' OVFDi.XCIAV'Li �1 � L i
�. Distance To:��
Wetlands
Drains
?. V;'ater Line Location 0 t..`
?. do PITC Pipe LAA
4. Septic Tank
y Tees - Length & To Clean Out Covers !✓�"�-�-
Coment Pipe to Tank - On Both Sides of Tank
�. Distribution Box
ll . As - Built Submitted
Lot Location
Dime_n-sio.ns of System
Location ;it}i Regard to P .cc `-Lest
El-evat;.ons
`„ater ;able
Cover ➢ Box - No Cracks
All Lines Flowing Equal Amounts
ITo Back Flow
S" , �
r.
Leach Field or Trench
Dions
.�t
l 1n
`
L T'
Sic.^e Lei h
-
Capped h.no.s
dL
Clean Double :'ached Stone
th
rvs
XT�ee
pe to Pit - Both
Sides
lbl_e �Tasr�ed. St,c^.e
8.
rTo Ga -', age Disposal
9.
Final In_snec-ion
10.
Bar, ar-;J-;n,y Covered S;s'�em -"
,
ll . As - Built Submitted
Lot Location
Dime_n-sio.ns of System
Location ;it}i Regard to P .cc `-Lest
El-evat;.ons
`„ater ;able
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&-)ara.of iAerlth
W13,%TFkCE DISPOSAL DM(RI Com% LIST
LOT
APPRWED DATE
DISAPPROVED DATE _
Provided:
Reasons:
}
2-
-Ti e D
FAII�
Reg 2.5
'The submitted plan mist show as a minimum:
!
{
) the lot to be served -area dimensions lot f,abatters
location and log deep observation hoes -distance to ties
c location and results percolation tests -distance to ties
design calculations & calculations showing required leaching area
location and dimensions of system -including reserve area
existing and proposed contours
g) location any gat areas within 1001 of sewage disposal system or
' disclaimer -check wetlands mapping
(hl surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any drainage easements t4thin 1001 of seinge disposal
system or disclaimer -Planning Bayard files
Sj) knom sources of rater supply trithin 2001 of sewage disposal
system or disclaimer
k) location of vmy proposed well to serve lot -1001 from leaching facility
(1) location of Water lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways
i
i
✓
(o) garbage disposals
p) no PVC to be used in construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
i
distribution box inlets and outlets, distribution field piping and
other elevations , ___
r) maxima ground grater elevation in area sei�age dispo sal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by last to prepare such plans
Reg 6
p/
SS!2tic Tanks
(a) capacities -150,% of flow, water table, tees, depth of tees,
access, pumping
b) cleanout
c) 10t from cellar va11 or inground swl=dng pool
F
(d) 25+ from subsurface drains
Reg 10.2 Distribution Boxes
1(a) slope greater than 0.08
Reg 10.1 V,l b) sump
6
TO: NORTH ANDOVER, MASS. ' 3 19$Z
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the construction materials of
said disposal system at
Site Location
North Andover, Mass.
The grades and construction materials
specifications dated
i
R&g2 Pro
phi VSs \ ecif ied in my plans and
q -Built .3O 19.
?"it 9
C. ,+�
�1NAS �
r�' Sanitarian
ISTE
C
NEW ENGLAND ENGINEERING SERVICES
INC
-I ANDO
HEALTH
25
January 23, 1996
North Andover Board of Health
Town Hall Annex
Main Street
North Andover, MA 01845
RE: TITLE V REPORT
Enclosed is the Title V report for 104 Carlton Lane , North Andover, MA.
If there are any questions please call me at my office, 686-1768.
Yours truly,
Benj n C. Osgood Jr.
President
33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
eparent of.
Environmental Protection
Wtillam F, Weld
C3o•emor
Trudy Coxe
sa ewy, =oeA
WN BOARD OF HEALTH tilt
d
David B; Struhs
Comrntuc�e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
�,p,�L ry/u • /fid • /� �vvr�rC, ��i�
Property Address: Address of Owner:
Date of Inspection; 3 (If different)
Narne of Inspector, Ty'e�j� i,',r C. C%S�j bu p,�� •NEW ENGLAND ENGINEERING SERVICES, INC..
Company Name, Address and Telephone, Number: 33 WALKER ROAD
P.O. BOR 536
CERTIFICATION STATEMENT . NORTH ANDOVER, MA 01845 508-686—L76.8
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 onsite sewage disposal systems. The system;
Passes
Conditionally Passes
Feeds Further Evaluation By the Local Approving Authority
Fads
Inspector's Signature: Date:
The Svstem 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 de sen, to the s+stem owner and copies sent to the puyer, if applicable and the approving authpnty,
INSPECTION SUMMARY;
Czech(VB, C, or D.
A'1 SYS/TEh1. PASSES:
t""'; 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.
81 SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired, The system; upon completion of the replacement or repair,
passes inspection,
Indicate. yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) .
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health
tr��:sc 6; :5/951
1
One Y Into; tr. t,t • oef;ar,, Mar;aaohrisetts 02105 o FAX (617) 556-11049 a Telophone (617) 292.55W
7W
SUBSURFACE SEWAGE DISPOSAL SYSTEM .INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:;/4 1/ eoloe` lon
Owner:
Date of Inspection;
a) SYSTEM CONDITIONALLY PASSES (continued);
Sewage backup or. breakout or high static water level observed in the distribution box is due to broken or obstructed
pipes) or due to a broken, settled or uneven distribution box; The system will pass inspection if (with approval of the.
Board of Health):
broken pipets) are replaced
cbstruption 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
insper,;on if (with approval of the Board of:Healthi:
broken pipets) are replaced
obstruction is removed
Cl FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH;.
Conditions exist which require further eva luation. by the Board of Health .in
public health, safety and the environment: .order to determine iLthe system Is failing to proteCt'th'e
1) SYSTEM.WlLL 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
CessNoa or privy, Is within 50 feet of a bordering vegetated wetland or a saltmarsh
?) Sy STEM WILL FAIL UNLESS THE BOARD OF HE,'OH tAND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERkIINES THAT
THE SYSTEM,15 FUNCTIONING IN A MANNER THAI PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
Tia ws:P.rt; nas.a.sept)c tanx ano:spd aasorptlon system and is within 100 febttu a ,,tfav� rata :(WPP:) o tr butary ,
surface Wirer supply ;
The systenl;ha. a,,septic tank and soil absorption syistem.and is within a Zone I of a public water. supply well..
The system has 'a septic tank and soil absorption system and is within SO feet of a private:water supply well:
The s}>tdni ha> a sept,c tank and soil absorption system and is less than 100 feet but .50 feet or more from a private water
Supp y 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 tha
ppm. n S
Dj SYSTEM FAIL5;
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 corren
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS.or
cesspool,
rev:aeo 8('5195) 2
> SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
// CERTIFICATION (conflnued)
Property Address; /Of �lf,`a'r F �/d %�ndr`!l,
Date of Inspection:
0) SYSTEM, FAILS (continued),
Static liquid level in the distribution box above outlet inver .due to an overloaded or clogged SAS or. cesspool:
T Liquid depth in cesspool isles;s:than 6 below invert or available volume is less,than;..1/2 day fluw•
Required pumping more than 4 times in the last year NOT due to clogged or. obstructed.pipe(s)•
Number of times pumped `
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
_ Any. porion of a cesspool or privy is with)n 100 feet ofa surface water supply or tributary to a surface water supply,
Any porion of a cesspool or privy'is within atone l of a public well,
Ani pon on.of a cesspool'or.privy is within SO feet of a private water supply well.
Ani portio. a cesspool or privy is less than 100 feet but greater than SO 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 FAIL$:
The following criteria'apply to large systems in addition to the criteria above:
The deslgr, flow,'of system is 10,000 gpd-or greiter !! arge System) and the system Is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a'surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water, supply
_ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) of mapped zone It of a
public Rater 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 6,0.0. Please consutl the local regional office of the Department for further information.
t: 3
I
9CO
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART S
CHECKLIST
Property Address: / 0,1e . C/fj x9l.X 'r 1 /, �✓ �,j J, illre
Owner:
Date of Inspection;.
Check if the following have been done
✓Pumping Information was requested,o. the owner; occupant, and Board of Health,
None of the system components have, been pumped for at least two weeks And the system has been iutgvMng normal flow rates
during that penod. Large volumes. of water have not been introduced !nto the systern recently or as pan of this inspection.
�'As built plans have, been obtained and. examined: Note If they are not available with N/A,
411�The fa ility or dwelling was Inspected for signs of sewage backup.
The system.does not receive non-sanitary or industrial waste flow
The site was Inspected for signs of breakout.
All system components,-excluding the,561 Absorption System, have been.located.on the site.:
The septk 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 Ibcation of the 5oil Absorption System on. the site has been determined based on existing:information or
approximated by.norninuus ve methods
T' e'ia ii,, e .a^d occ p, .r if dl!ierc Irprr. o�\ne, wero provided with information on the proper maintenance of Sub,
Surface snosaJ System.
Ln
(:evisa a%:5x551
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART C
n SYSTEM' INFORMATION
Proner•t..y Address: % 0 (. E'� f oil f lJ�i /l�0 fi�cioIia,
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: kallon5
Number of,bedrooms;
Number of current residents;
Garbage.grinder (yes or no);
—41
Laundr,, connected to system (Yes or not
Seasonal use(Yes or no),--AA
water meter readings, if available, %jf�� .../7 �!/r/�B//
Laai date of.occupancy.0
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flowi, gallons/day
Grease trap present: (yes or nol,:,
Industrial Waste.Holding Tank present: (yes or no)'
Non-sanitary waste. discharged to the Title 5 System: (yes or no)�
Wafer rneter readings, if available:
Last date of occudancY
OTHER: tDescribei
Las; dale of occupancy
GENERAL INFORMATION
PG RECOR S an source of information
s� - 1n '9
Systern pumped as pan of in<pection (yei'or no)
If yes, volume p;,mped >S�n1 ratio+ts
Reason for pumping. sPE�
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system lyes or no) (if yes, attach previous inspection records, if:any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when.arriving at the site: (yes or nol �VcJ
(revl&ed 6/15/951 5
5U8SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INyjFORRWTION (continued)
Property Address /0'.y
0y
Owned
Date of lnspecticn:
SEPTIC TANK,.—
(locate
ANK:(locate on site plan) .
Depth 'below grade:� ,
Material of construction //concrete .,,,.Metal FRP other(explain)
Dunenslon5: C X
;luc ge depth; {" ,
Distance from: top of sludge to bottom oI outlet lee or banle;,3 L ,
Scum th ckness:`�
Distance from top of scurf to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle, /9"
Camments,
(receme ,endation (or pumping, condition of inlet and outlet. tees or baffles,
depth of liquid lew.e2l in relation to outlel� invert, structural
(I i h [- ` "4�0 1) `.GG �S �� �V7 �6 i P, S /q�r%r/'f�S' �I/i i Nd Q{/Y�D �.'N�•C�
inteorir', evidence o Oaka),e: etc.) � K .7�' Tra
GREASE TRAP;
(locate, cn site plant
Dep, , b ow grade:
,materioi of construcaion concrete _,_.metal FRP oiher(explain)
Dirr,en5ions.
un
Distance from tap Of scumto tpb of outlet tee or.ba(fle
n <•�- fram.b0(tQr r' c�ii. rn-nntip^' Qi outlet tee a, bat'.lE :
y0
Comore t
trecom ..endauon for purip,r,�, tend t or, of inlet and outlet tees ar baffles, depth of liquid level in relation to outlet invert, structural
integrih, evidence of iaai aee etc.l 1
�W-"
r
Iil. iia
SUB SURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FOR/vi
PART G
SYSTEM INFORMATION (continued)
Property Address-_ !c C($f
Owner: IYIA R�1N
Date of )nspection:
TIGHT OR HOLDING TANK: _
(locate on site plan)
Death below grade;
Material of construction_concrete _metal FRP other(explain)
Dimensions,
(apathy. gallons
gallons/da1'
Alarm level:
Comments;
!condition of inlet tee, condition of.alarm and float switches, etc:) .
D15TRIBUTION. BOX;
(locate ^n 5ite plan;
C)epih of liquid level abo,�e,'outlet inverl:
Comments
tno, ;C if level and d5 e�,,F1' P Irinn.e pf fel d; c8'rn'r+ve,, evidence of leakage Into or out of box, etc 1,
PUMP CHAMBER:
(locate on site plan;
Pumps in working order:(yes or no)
Corrments
(note condition. of pump chamber, condition of pumps and appurtenances, etc.)
Ir2r_sed
6111195). 7
' SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
++ SYSTEM INFORMATION: (contlnued)
Properts• Address
Owner: rn 4P
Oate of Inspection: I� a i SAO
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:
1"p� •
leaching pit5,:nurnber._
leaching.chambers; number:
eaching galleries, number
leaching `trenches, number,length:�
leaching fields, slumber, dimensions: CAO
O''erflow cesspool, number:
Comme-rts (note condition of soil, signs of hydraulic failure, level of ponding;. condition of vegetation,etc.)
ho re b UL- c i�v�iZ Q�ouw{p Now tweieep
CESSPOOLS:
(locate or, site plan).
Number and configorallor,
DeG'h. i o hcuid to niv i n v e
Dep! h,csr,dids la?e;
p
,.Depth e. scum layer:
.Dirren,,w-- of cesspool:
Malerial'S of construction:
Ind tial e, of groundwate'
-nfiow (cesspool mus be pumped as pan of inspection)
Cbmmer::s (no(e Gond t er of so 1, signs of hydraulic failure; level of ponding, condition of vegetation, etc,)
:PRIVY:
Morale on site plan)
Waterials of construction: Dimensions;
Depth of solids,
Comments: (note'c.ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
lrtv!,ed ?'25/55( 8
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:)
SYSTEM OWNER & ADDRESS 41
SYSTEM LOCATION
(example: left front of house)
,6q G /
OCT - 3 200{ _
DATE OF PUMPING: �'d"-C�/ QUANTITY PUMPED�GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES •
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
FULL TO COVER
HEAVY GREASE
BAFFLES I1V PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Anooy2r S
COMMENTS:
�1_
..�if_ S I
_CONTENTS TRANSFERRED TO: I}'�Qd/144k_
-T
r _
Compionwealth of. Massachusetts
City/Town of. NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other appro� ing all ry 2006
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
P%- FaAnny IlnVrrTIMIU l
1. System Location:
Address .
k) Ayi
City/Town
2. System Owner:
Name �] L/—_
Address (if different from location)
C ity/Town
B. Pumping, Record
1. Date of Pumping
3. Type of system: ❑
❑ °Other (describe):
TU:,,,, OF NORTH ANDD'
hEALTH DEPARTME,N, I
UP
State Zip Code
5taZip � pgie
Telephone Number
/I 06 /goo
D 2. Quantity Pumped: canons
'Cesspool(s) 5 Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present?*Yes ❑ No If yes, was it cleaned? 'gKes ❑ No
5. Condition of System:.
6. Sy em Pumped By:
Name11
Aw.(,ac &
Company
7. /Location where ,coontents were dispose
I'f
FJI'P�w 00/ n�,�
Vehicle License Number
Signature of Hauler Date rZ 06
http://www. mass. gov/d6p/water/approvals/t5forms. htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
N
g,.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
Y TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1,04 60rh�dI
Owner's Name: Al
Owner's Address:
Date of Inspectiol
Name of Inspecto
Company Name:
Mailing Address:
Telephone Numb
RECEIVED
SEP - 3 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMC"
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �//,�,,� �t Date: ?' 30 O�
f
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
5
Page 2 of l 1
` OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
'CERTIFICATION (continued)
Property Address: 104 Pat - 'w
Owner: J 1V
Date of Ins ection:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
have not found any information which indicates that any of the failure criteria described in. 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: f �t k /A
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the followin- statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally .
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed
2
i
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: IN Z- V
e tr
Owner: /
Date of lnn(ec�tidd.
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
4
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within .100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within.a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other: .
3
Ok " to Page 4 of l 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: gwjak
Date of Insrpectii n:
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
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.
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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
At1 (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: t„(,fr' Al
fk
Owner: J /tr'
Date of Ins ecti :
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes o
_ _ 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 ?
_/414 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:
Yes no
_I �__,.,'Existing information. For example, a plan at the Board of Health.
— Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: (l CJV
t^ e
Owner:,
Date of Ins ectid :
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N
Number of current residents: 3
Does residence have a garbage grinder (yes or no): LesM uT' 7-U a a V S
Is laundry on a separate sewage system (yes or no) -)6 u [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): /_/1u
Water meter readings; if ava'aable (last 2 years usage (gpd)):
Sump pump (yes or no): _
Last date of occupancy: CD eeor r Ci
COMMERCIAL/INDUSTRIAL r
Type of establishment: fi
Design flow (based on 310 CMR 15.203):_ gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: CT ;)00 3
Was system pumped as part of the inspection (yes or no): !,
If yes, volume pumped: CVU gallons -- How was quantity pumped determined?
Reason for pumping: �W e ("re 7-4 H(d-- S rot^ ruv
TYPE -OF SYSTEM
Septic tank, distribution box, soil absorption system
_ Single cesspool: :
Overflow cesspool
Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
_ Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): &0 0
Page 7 of 1 I.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: &17�AdV,
e
,Owner:
Date of Lns- ectiod:
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction: -0'c—astiron 40 PVC - other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, T evidence of leakage. etc.):
�1� l,� i� 6 oU �� fryN of T7r� �c✓
SEPTIC TANK./j S(locate on site plan)
f
Depth below grade: '
Material of construction: �oncrete _metal _fiberglass _polyethylene
—other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of
certificate) i r p . r.
Dimensions: / Q r Q
Sludge depth: G/'' . ,r
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:
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
GREASE TRAP: 1 '` _(dateon site plan)
Depth below grade:
Material of construction:,—concrete metal fiberglass polyethylene _other
(explain): — —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
t "
' Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: %"
Owner:
Date of Ino cf
TIGHT or HOLDING TANK:/Y�tank must e
( b pumped at time of mspection)(locate on site plan)
Depth.below grade:
Material of construction: concrete - metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
S
DISTRIBUTION BOX: (t (if present must be opened)(locate on site pian)
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
COOP
- ,--'u cus /=e; ria
CHAMBER: (local
1A-
PUMPn sitelan
P )
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.):
8
A
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/h� SYSTEM INFORMATION (continued)
IU
Property Address: 0A;-#&A1Y
Owner• IqZe d!
Date of Inspect
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length`.
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/altemative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
CESSPOOLS: f ' (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate oa 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.):
9
r
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Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address
At e
Owner• I
Date of Ins ecti
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
�ao1
c 3G�
10
y
' Page 1 I of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: S
Date of Ins ecti
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells-
Estimated
ellsEstimated depth to ground water, - feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
6served site (abutting property/observation hole within 150 feet of SAS)
_ Checked with local Board of Health-explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
y
Commonwealth of Massachusetts
Cit
y/Town of NORTH ANDOVER MAS S
10
System Pumpirlig Record
a Form 4 n1�
City/Town
State Zip Code
Telephone Number
B. Pumping; Record
1. Date of,Pumping , Date v 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s)Septic Tank ❑ Tight Tank
❑ 'Other (describe):
4. Effluent Tee Filter present? 'R/Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
' V
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
-7q-6- (0
Vehicle License Number
Signature of Hauler Date
http://www. mass. gov/d6p/water/approvals/t5forms, htm#inspect
t5form4.doc• 06103 System Pumping Record • Page 1 of 1
.g
DEP has provided this form for use by local Boards of Heal � uu� Record must
be submitted to the local Board of Health or other approvin
A. Facility Information
Important:
When filling out
1. System Location:
forms on the
0
computer, use
only the tab key
Address
to move your
cursor - do not
n 1 y f1 i,�
� � ! � � {rJ_
p
use the return
Cit (Town
y State
Zip Code
key.
2. S re.m Oumer:
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping; Record
1. Date of,Pumping , Date v 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s)Septic Tank ❑ Tight Tank
❑ 'Other (describe):
4. Effluent Tee Filter present? 'R/Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
' V
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
-7q-6- (0
Vehicle License Number
Signature of Hauler Date
http://www. mass. gov/d6p/water/approvals/t5forms, htm#inspect
t5form4.doc• 06103 System Pumping Record • Page 1 of 1