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Home My WebLink AboutMiscellaneous - 1041 JOHNSON STREET 4/30/2018 (2)CDC f orN qy 6628 h + 9 Town of North Andover ` HEALTH DEPARTMENT CHECK #: DATE: I LOCATION: • alt_ '11�.� fiil h:J1�i7 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) $ ❑ Title 5 Inspector $ "�16 Title 5 Report $� ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1041 'ohnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. City/Town 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. RECi;iViFrr% Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ rerum A. General Information 1. Inspector: Dean Dynan Name of Inspector Company Name 2 Suntaug Street Company Address Lynnfield City/Town 508-726-9935 Telephone Number B. Certification OCT 31 2013 TOWN OF NORTH ANDOVER HEALTH Ma State SI 12837 License Number 01940 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 ❑ Nee Further Evaluation by the Local Approving Authority . . ector's Signature Date 111 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. l5ins • 3/13 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 1041 Johnson Rd Property Address Ocean City Development Llc Owner's Name N. Andover Ma 01845 9/30/2013 Citylrown 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: Three bedroom dwelling with septic tank and pipe in stone drain field 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 • 3/13 Title 5 Official Inspection Form: 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 1041 Johnson Rd Property Address Ocean City Development Llc Owner's Name N. Andover City/Town B. Certification (cont.) Ma 01845 State Zip Code 9/30/2013 Date of Inspection 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 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 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 Y day flow t5ins - 3/13 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 1041 Johnson Rd Property Address ❑ Ocean City Development Uc Owner Owner's Name ❑ information is required for N. Andover Ma 01845 9/30/2013 every page. Cityrrown 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- 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name nformation is required for N. Andover Ma 01845 9/30/2013 every page. CityTTown 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 i 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 ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 GPD l5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. City/Town D. System Information Description: three bedroom single familv home State Zip Code Date of Inspection Water meter readings, if available (last 2 years usage (gpd)): Detail: see attached 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 occipied Date ❑ Yes ❑ No ❑ Number of current residents: ❑ 1 ❑ Yes Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: see attached 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 occipied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State Zip Code Date General Information Date of Inspection pumped as part of inspection Was system pumped as part of the inspection? If Inc volume um ede 1000 ® Yes ❑ No y ' p p gallons How was quantity pumped determined? meter on pump truck Reason for pumping: In need of service after measurement of tank 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. 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: 1972 as per homeowner information Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 20" feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): building sewer in good condition no evidence of leakage Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1000 gallon concrete tank If tank is metal, list age: ❑ Yes ® No 12" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'X 5'X 5'H Sludge depth: 22" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Z Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 8" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? infield with measure stick and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank should be pumped every 2 to 4 years depending on number of occupants and usage Septic tank is in working order inlet has concrete baffle in good condition / outlet has a pvc T with gas baffle and zable filter Liquid is at bottom of pipe on outlet line with separation from inlet and outlet Septic tank in good condition / there is no evidence of leakeage into or out of tank Three covers with in 12" of grade Zable filter cover on outlet line has cover to grade for easy service / Zable filter should be cleaned every vear to avoid tank back uD see form attached Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • 3/13 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons ❑ polyethylene ❑ other (explain): 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System For M 1041 Johnson Rd D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert water at bottom of outlet lines 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.): Concrete D box in good condition 4 outlet lines with water at bottom of invert / box is level and there is no evidence of leakeage into or out of box / no evidence of system back ups with scum layers above bottom of outlet invert/ D box has on concrete riser and cover is located 12' below qrade 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 ection Form m - Not for Voluntary Assessments Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. City/Town 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 water at bottom of outlet lines 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.): Concrete D box in good condition 4 outlet lines with water at bottom of invert / box is level and there is no evidence of leakeage into or out of box / no evidence of system back ups with scum layers above bottom of outlet invert/ D box has on concrete riser and cover is located 12' below qrade 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo �^M 1041 johnson Rd ection Form rm - Not for Voluntary Assessments Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 6 that equal 200' ❑ 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.): SAS in working condition / no evidence of breakout / located in green grass area / no ponding / vegitation in good condition / soils in good condition Leach trenches are 32" from grade see attached 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. City/Town 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 r t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name nformation is equired for N. Andover Ma 01845 9/30/2013 every page. City/Town State Zip Code 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1041 Johnson Rd Owner information is required for every page. Property Address Ocean City Development Llc Owner's Name N. Andover Ma 01845 9/30/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells d th t h; h d t 51+ Estimatedep o Ig group wa er. feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 01 If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: The house has a sump pump and the pit is located 5'+ below grade Checked plans on file for abbutters no plan on file for homeowner 1029 Johnson st eshw 5'+ as per title 5 report on file dated 2008 1057 Johnson st eshw 5' as per plan on file at BOH dated 1995 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1041 johnson Rd Property Address Ocean City Development Llc Owner Owner's Name information is required for N. Andover Ma 01845 9/30/2013 every page. Cityrrown 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 5/10/2013 11:40:29 AM by Karen Hanlon Town of North Andover Tax Map # 210-107.A-0150-0000.0 Parcel Id 17975 1041 JOHNSON STREET KLAPES,JEANNETTE 1041 JOHNSON STREET N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.04 Acres FY 2013 UB Mailina Index Name/Address KLAPES,JEANNETTE 1041 JOHNSON STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 13307.0 - 1041 JOHNSON STREET 2100300 02 Cycle 02 UB Services Maint. Account No. 2100300 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Type Loan Number Payor Active/Inact. From Occupant Name Active/inactive Last Billing Date 3/5/2013 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 15.20 /1 Until Account No. 2100300 Serial No Status Location Brand Type Size YTD Cons 13242522 a Active ERT HH METE METE w Water 0.63 0.63 148 Date Reading Code Consumption Posted Date Variance 5/1/2013 263 a Actual 2 -43% 2/5/2013 261 a Actual 4 3/13/2013 -8% 10/31/2012 257 a Actual 4 12/13/2012 38% 8/3/2012 253 a Actual 3 9/26/2012 -1% 5/3/2012 250 a Actual 3 6/20/2012 -39% 2/2/2012 247 a Actual 5 3/14/2012 -81% 11/1/2011 242 a Actual 26 12/15/2011 17% 8/2/2011 216 a Actual 22 9/14/2011 31% 5/4/2011 194 a Actual 16 6/13/2011 66% 2/7/2011 178 a Actual 11 3/15/2011 153% 11/1/2010 167 a Actual 4 12/13/2010 -42% 8/3/2010 163 a Actual 7 9/13/2010 75% 5/4/2010 156 a Actual 4 6/9/2010 1% 2/2/2010 152 a Actual 4 3/11/2010 -3% 11/2/2009 148 a Actual 4 12/11/2009 -30% 8/5/2009 144 a Actual 6 9/11/2009 -37% 5/4/2009 138 a Actual 9 6/16/2009 88% 2/5/2009 129 a Actual 5 3/16/2009 -16% 11/5/2008 124 aActual 6 12/10/2008 21% 8/4/2008 118 a Actual 5 9/12/2008 -58% 5/2/2008 113 a Actual 11 6/18/2008 53% 2/6/2008 102 a Actual 8 3/14/2008 26% 11/2/2007 94 aActual 6 1/15/2008 50% 8/3/2007 88 a Actual 4 9/14/2007 5% 5/4/2007 84 a Actual 3 6/22/2007 -22% 2/21/2007 81 a Actual 6 3/23/2007 -18% 11/1/2006 75 a Actual 6 12/22/2006 43% 8/1/2006 69 a Actual 4 9/13/2006 -22% 5/5/2006 65 a Actual 5 6/20/2006 7% l�tAi1�T�:b�ine�f � � � �r � r -•. APPLICATION•fOR SEWAGE DISPOSAL INSTALLATION i HEALTH DEPARTMENT - NORTH ANDOVER, MASS. ,..., , Pagp �,:of 3 bmake application for a permit for a sewage disposal installation at -<' ..�^ I will install this system in ac- cordance with alll�the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Ref:1659992051145ftether, I will construct the house sewer_.of_ bell and. spigot--. pipe,-. the_. minimum - diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of,r,.r`-"J in size. A manhole (s) / • permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a' series of trenches, the bottom of which will pro- vide a minimum of r9"1 lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8t1 to 1/41, (dia.) will be placed over the -course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. i further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plane must be submitted with application. DATE �rl VL/ ? •"�.° I hereby issue the above Andover, {Ma�Achusetts. DATE Signature of Applicant permit for the Board of Health of the Town of North Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer / w Percolation Test Garbage Grinder ttp://web.mail.comcast.nedzimbraiWprintmessage2id=372320&tz=America/New_York&xim=1 5/6/201.3 7- io r Ao -PR) 'too _ai) p H WS 0 W 5`7-11� rVT `1\_ Commonwealth of Massachusetts W City/Town of No Andover W° System Pumping Record Form 4 i^M 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ A. Facility Information 1. No Andover MA CitylTown State Zip Code 2. System O e Name Address (if different from location) City/Town B. Pumping Record State i Te!ephone,Number Zip Code 1. Date of Pumping' L2. Date Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 C Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 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 City/Town of 'No Andover f System Pumping Record Form 4 I DEP has provided this form for use by localoB`-96cls 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. f=acility Information System Aacress City/Town State 2. System Owner: yo M Name Address (if different from location) City/Town State Telephone Number B. Pumping Rec®rd 1. Date of PumpingDat-— 2. uantity Pumped: 3. Component: ElCesspool(s) ;Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? Yes ❑ No 5. Observed condition of component pumped: C'-(!"' '/ Zip Code Zip Code Gallons ❑ Grease Trap If yes, was it cleaned? Yes ❑ No 6. System Pum-p7e-dd By: Name Vehicle�License Number Stewarts Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 -omill st bradford ma Signa ure of Ha6ler Date Signature of Receiving Facility (or attach facility receipt) Date t5form4.doc- 11/12 System Pumping Record - Page 1 of 1