HomeMy WebLinkAboutMiscellaneous - 1044 SALEM STREET 4/30/2018ti v
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
r
Form 4 MAY 15 2007
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
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rein
DEP has provided this form for use by local Boards of Health. Other forms ='-ZW1Qf(-�
r3CJ1 MEDVER
information must be substantially the same as that provided here. Before th our
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:
Address
(04L( �
Cityrr wn
2. System Owner:
Name
Address (if different from location)
coo (--Vkk
State
Zip Code
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
D- i0 0
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑
❑ Other (describe):
Gallons
Cesspool(s) b septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes l- Ivo If yes, was it cleaned? ❑ Yes ❑ No
5. Condi ion of System: �
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6. Syst@nli
Pumped B
" fa t
Namev' Vehicle License Number
Company Y
7. Locati where c tent ere disposed:
. A I
Date
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ro -d'i
System Pumping Record • Page 1 of 1
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Of NORTp
• Town of North Andover
,SSACNU5�4
CHECK #:
LOCATION:
H/O NAME:
CONTRACT(
Tyne
of Permit or License: (Check box)
O
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)
$
❑T'
5 Inspector
$
Title 5 Report
$
❑ Other: (Indicate) $
24 31 Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
I
t MOFTH.
1 9
• . Town of North Andover
HEALTH DEPARTMENT
.. ,'TSACM�SEt
CHECK #: c %%' ~ DATE:
LOCATION:
7-
H/O NAME: � O l'�
CONTRACTOR NAME:
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) $
❑ TiTitff'5- Inspector $
l Title 5 Report $
❑ Other: (Indicate) yl ''� $
V
2431
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
0,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL
TITLE 5
W
MAY 15 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _1044 Salem Street_
_ North Andover_
Owner's Name: Jerry Petrosillo & Patricia MacDonald _
Owner's Address: _1044 Salem Street _
—North Andover, MA 01845_
Date of Inspection: 5/10/2007
Name of Inspector: Neil J. Bateson_
Company Name: Bateson Enterprises Inc.
Mailing Address: _111 Argilla Road_
_Andover, MA 01810
Telephone Number: _( 978 ) 475-4786_
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: � Date: _5/10/2007_
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.
Page 2 of l l ;
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _1044 Salem Street
_ North Andover_
Owner: _ Petrosillo & MacDonald _
Date of Inspection: 5/10/2007 _
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
X 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. Answer yes, no or not determined (Y,N,ND) in the 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.
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):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 df 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _1044 Salem Street
—North Andover_
Owner: _Petrosillo & MacDonald _
Date of Inspection: _5/10/2007 _
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
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:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _1044 Salem Street
—North Andover_
Owner: _Petrosillo & MacDonald_
Date of Inspection: 5/10/2007 _
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
_ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No Liquid depth in cesspool is less than 6" below invert or available volume is'/Z 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
_ No Any portion of the SAS, cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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.]
No (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: _1044 Salem Street
_ North Andover _
Owner: _Petrosillo & MacDonald_
Date of Inspection: _5/10/2007
Check if the following have been done. You must indicate `yes" or "no" as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health
No Were any of the system components pumped out in the previous two weeks ?
Yes_ _ Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
Yes_ _ Were as built plans of the system obtained and examined?
Yes ` Was the facility or dwelling inspected for signs of sewage back up ?
Yes _ Was the site inspected for signs of break out ?
_Yes _ Were all system components, excluding the SAS, located on site ?
_Yes_ _ 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 ?
_Yes_ _ 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
_Yes_ — Existing information.
_Yes_ _ 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)]
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _1044 Salem Street_
–North Andover_
Owner: _Petrosillo & MacDonald_
Date of Inspection: 5/10/2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 _440_
Number of current residents: _3
Does residence have a garbage grinder (yes or no): Yes_
Is laundry on a separate sewage system (yes or no): _No _
Laundry system inspected (yes or no):
Seasonal use: (yes or no): _No
Water meter reading: Yes_
Sump pump (yes or no): Yes_
Last date of occupancy: _ Current _
COMMERCIALtINDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): _gpd
Basis of design flow (seats/persons/sqft,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: Pumped 2006, owner _
Was system pumped as part of the inspection (yes or no): _Yes_
If yes, volume pumped: _1000_ gallons -- How was quantity pumped determined? _Measured tank_
Reason for pumping: _Inspect tank & baffles_
TYPE OF SYSTEM
X_ 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 _Tank 30 years old, d -box
& pits 18 years old, 5/23/1989, as built plan, As built plan _
Were sewage odors detected when arriving at the site (yes or no): _No_
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _1044 Salem Street_
_ North Andover _
Owner: _Petrosillo & MacDonald_
Date of Inspection: _5/10/2007
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _22"
Materials of construction: _X cast iron _X 40 PVC _other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" Cast iron thru wall, 3" PVC in house.
No leaks visible
SEPTIC TANK: X
Depth below grade: _10" _
Material of construction: X concrete _ 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)
Dimensions: 7'x 5' x 4'
Sludge depth3"_
Distance from top of sludge to bottom of outlet tee or baffle: 29" _
Scum thickness: _3"
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: _13" _
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 baffle ok. Outlet baffle ok. Depth
of liquid at outlet invert. No evidence of septic tank leaking. _
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 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _1044 Salem Street
North Andover_
Owner: _Petrosillo & MacDonald_
Date of Inspection: 5/10/2007_
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/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.):
DISTRIBUTION BOX _X_ ( locate on site plan )
Depth below grade 36"_
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, one line to pits. Evidence of light carryover,
pumped d -box to clean. D -Boz cover broken, replaced it. No evidence of leakage._
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no): —
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _1044 Salem Street _
_ North Andover_
Owner: _Petrosillo & MacDonald_
Date of Inspection: _5/10/2007_
SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
X leaching pits, number: _3 pits in series
leaching chambers, number: —
leaching galleries, number:
_ leaching trench, number, length:
leaching field, 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.): –Soil ok. Vegetation ok. No sign of ponding to surface. Camera inside of pit thru outlet in d -box. No
liquid to invert
–
CESSPOOLS:
Number and configuration: _
Depth – top of liquid to inlet invert: —
Depth of sludge 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 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.):
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _1044 Salem Street _
_North Andover_
Owner: _Petrosillo & MacDonald_
Date of Inspection: _5/10/2007
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
A to 1 = 24'
Ato2=28'
Bto1=21'2"
Bto2=17'
B to D -Boz =16'
C to D -Boz = 37'
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _1044 Salem Street _
—North Andover_
Owner: _Petrosillo & MacDonald_
Date of Inspection: _5/10/2007 _
SITE EXAM
Slope _ No _
Surface water _ No _
Check cellar _ Dry _
Shallow wells _ No
Estimated depth to ground water _ >6' _
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:
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)
X Accessed USGS database -explain: Essex County Soil Map
You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 36,
Hinckley Soil, Water >6'Deep_
Commonwealth of Massachusetts
City/Town of
System Pumping Record
yForm 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.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key-
A. Facility Information
1. System Location:
Address f O Li p r
City/Town
2. System Owner.
Address (if different from location)
Cityfrown
hv%�aSe-
State Zip Code
Mshe- Dcr/\a f
B. Pumping Record
5 10 -017
1. Date of Pumping
3. Type of system:
Date
❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes L- Ivo
State
Telephone Number
2. Quantity Pumped:
Zip Cale
=
Gallons
E3 -'Septic Tank ❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
5. Condi ion of System:
6. SystP' Pumped B;y� �
(\J Q� � 'd
Name Vehicle license Number
Company
7. Locati where rtentnere disposed:
d -di
SiOapUe Af Fgmfiauder Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Summary Record Card generated on 5/10/200710:51:13 AM by Lisa Warren
Town of North Andover
. Tax Map # 210-106.A-0060-0000.0
1044 SALEM STREET
PETTROSILLO, JERRY
1044 SALEM STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type
Size Total 0.49 Acres
FY 2007
Page 1
1 Residential
UB Mailing Index
Name/Address
Type Loan Number
Active/Inact. From
Until
PETTROSILLO, JERRY
Payor
1044 SALEM STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 17303.0 -1044 SALEM STREET Last Billing Date 4/2/2007
3160380
03 Cycle 03
Active
UB Services Maint.
Service Code
Rate Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8 7.82
1/
WTR WATER
01 ALL METER SIZE 110.25
A
UB Meter Maintenance
Serial No Status
Location Brand
Type Size
YTD Cons
16337141 a Active
ERT METE METE
w Water 0.63 0.63
0
Date
Reading
Code Consumption
Posted Date
Variance
3/9/2007
826
a Actual
30
4/16/2007
-26%
12/6/2006
796
a Actual
39
1/19/2007
51%
9/7/2006
757
a Actual
25
10/20/2006
-11%
6/12/2006
732
a Actual
28
7/10/2006
35%
3/17/2006
704
a Actual
22
4/17/2006
-2%
12/15/2005
682
a Actual
23
1/17/2006
-43%
9/12/2005
659
a Actual
42
10/14/2005
-3%
6/7/2005
617
a Actual
42
7/15/2005
94%
3/5/2005
575
m Manual estimate
20
4/5/2005
-3%
12/8/2004
555
a Actual
20
1/14/2005
-51%
9/15/2004
535
a Actual
48
10/8/2004
39%
6/9/2004
487
a Actual
19
7/30/2004
31%
4/16/2004
468
a Actual
34
5/17/2004
0%
12/11/2003
434
n New Meter
0
12/11/2003
0%
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 1044 Salem Street, North Andover
Owner: Petrosillo & MacDonald
Date of Inspection: 5/10/2007
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Ne 41sn
Bateson Enterprises, Inc.
COMMONWEALTH OF MASSACHUSETTS
ExECLTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET: BOSTON: NIA -0210$ 617-292-55001 .
WILLIAM F. WELD TRUDY COXE
Secretin
Govemo:
ARGEO PAUL CELLUCCI DA VID B. STRUHS
Lt. Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissiorra
PART A .
CERTIFICATION
Property Address: 10 4 &ja' j L- �. .f JO^T " FI ; •��dress of Owner:
Date of Inspection:—`U pf different)
Name of Inspector:
0 QA
1 am a DE pr veq d.system in for pursuant to. Section t9.3d0 of Tithe 5 (310 CMR 15.000) ,
Company Name: -E4i
Mailing Address:
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true; accutate
and complete'as of the time of inspection. The inspection Was performed based tin my training and experience in the propel function and
maintenance of on-site sewage disposal systems. The systemi
_V Passes P
_ Conditionally Passes
_ Needs rther aluation By the Local Approving Authority
Inspector's Signature: Date:
The System Inspector shall submit a c y of This inspection tepor`t to the Approving Authority Within thirty (30) days of tompfeting this
inspection. If the system is a shared Mt6m or has a design flow of 10,000 gpd or greater, the insp d the "systeM oNirter (hall submit
the report to the appropriate regional office of the Department of Environ ental totectian1$,h igmat hould be fent to the system owner
and copies sent to the buyer, if applicable, and thea '" rovint adthori
P PP g ty
IN SUMMARY: Check A, B, C; of ,t: i
JAN 2 2 !8
AI SYSTEM PASSES:
CI -11 "have found any information which indicates that the system violates any of tits failure vita fa as fiefined in 316 CMR 15.303.
Any failure criteria not evaluated are indicated below:
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass" section need to be replabed or iepalred:. 71tp.3ystem, upon
completion of the replacement or repair, as approved by the Board of Health; will Past•
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances If "not determined", explain Why not.
The septic tank is metal, unless the owner or opetat& has pr&lded the systerm. inspector With a copy.of a Certificate of
Compliance (attached) indicating that the tank Was ihstalled v` win twenty f2t)) yeais prior W the date of the i.Mpearoh or
the septic tank, whether or not metal, is clacked, ftticturally unsound, shows substantial infiltration of iexfiltration, or tank.
failure is imminent. The system Will pass iitspectton,if the ezitting $6pti6 tank is teplaced with a ton foirrttttg Peptic tank
as approved by the Board of Health.
(revisid 04/25/97) , aa$i bf l0
DEP on the JVorld Wide tNeb: httPalwVirw.tniigrietstate.ma.tis/dep
10 prjnwi on Recycled Paper
N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Address: C) L/W
Property (�
Owner:�IY�DU��1G2
Date of Inspection: t,/t
BJ 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 o(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 replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: y
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 1N 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) DETERMINE5 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 (Sr1S) and the 5A5 it within 100 feet to a sudace.iivater W001Y or
tributary to a surface water supply.
_ The system has a septic tank and Soil ab'Sorption system and the SAS is within a Zone I of a publit water supply well.
The system has a septic 'tank and soil absorption system and the SAS iS Within 50 feet of a privatf Wsw supply well.
_ The system has a septic tank and "soil absorption system and the SAS it less than 00 feet but 56 (60 or More from a
private water supply well; unless a well water analysis for coliforiin bacteria and V6W06 brgamc cbrnpoi lids 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 (approkih�itiion .not walid):
3) OTHER ;
(revised 04/25/97) Piigs 2 c! 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address , Q 7 PSA9"
—
��-�- f f-'
Owner C4 r
Date of Inspection: '
_-0 1
D] SYSTEM FAILS::
You,must indicate either "Yes" or "No' as to each of the following:
.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
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge ar ponding Qf effluentfito 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 inyen due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within x100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a. public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
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 11 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 04/25/97) Page 3 of to
SUBSURFACE SEWAGE "DISPOSAL SYSTEM INSPECTION FORM
PART B
°; CHECKLIST
PropertyAaaress I O Qom. P�l
DateCrz—
of Ittspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes
Pumpingr 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
t as part of this inspection.
V As built plans have been obtained and examined. Note if they are not available with N/A.
I The facility or dwelling was inspected for signs of sewage hack -up.
The system does not receive non -sanitary or industrial waste flow.
„The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were, uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
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.
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))
.. tTw���d.04I35I8?) 3 "PRS Ot 10
n
Number of bedrooms: � (
Number of current residents: `7
Garbage grinder (yes or no).S
Laundry connected to cyst m yes or no)
Seasonal use (yes or r!o):�
Water teeter readings, If available (last two (2) year usage (gPd) 6 S
Sump Pymp (yes or no):
Lastdateof^occupancy ct' ` l - a��o :� Aa'
. COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow; aallons/day
Grease} crap present lyes or no)
IndustrialWaste Holding Tank present lyes or no)`_
Non-sanitaty,waste discharged to the Title 5 system? (yes or no)
Water meterreadings, if available:
Last date of occupancy
OTHERS (Describe)' _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information,
System pumped as part of in ction: (yes . r no)
If yes volume pumped: _gallons
Reason for pumping:
TYPE OfSYSTEM
i/ 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)
I/A Technology etc. Copy of up to date contract?
Other
APPR XIMA AGE of all comport nts, date installed (if known) and Wurcefin ormation:
YAA-�-.
Sewage odors detected when arriving at the site: lyes or no) NG
(rwised 04/25/97)
16
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
,E PART C
SYSTEM INFORMATION (continued)
f -
Property Address: '
Date of Ilan tion:
BUILDING SEWERF
(Locaie on site plan)
' 1
Depth- below grade:
Material of construction: iron _ 40 PVC _ other (explain)
Distance fromprivate' water supply well or suction line:
Diameter If f ..
Comments: (conditio of joi ts, venting,,evidence of leakage; etc.)
SEPTIC TANK:
(locate on site plan)
.use -1 0��r 1a
Depth below grade.
Material of construction: trete _metal _Fiberglass _Polyethylene ,_,other(explain)
If tank is metal; list age" Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions:
Sludge dept49Lh 'y +t
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness._ h
Distance from top pf scum to top of outlet tee or baffle: C ` ti �' A 1
Distance from bottom of scum to bottom of ouhet tee or b ffle: Vp C'r
How dimensions were determined: S' �{_pac ���" «`JJJ ___
Comments:
(recommendation for pumping, condit' of inlet and o ttet tees or .es, de h of (i uid lgfl i rela 'o to out i rte, st� Aral
integrity.-evjdt<nce of lgakage, M.) � ., t,. a n AA C'9
GREASE TRAP: Novle—
(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: Y
(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.)
(rwiaod 04/25/9?i Ysg� 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAtION (continued)
O
Property Address: `(.i 4y1C-30I."-t�-
Owner:
Date of Inspection: t e)
TIGHT OR HOLDING TANK: (Tank must be pumped ptio'r to, of at time, of inspection)
(locate on site plan).
Depth below grade:
Material of construction: _Concrete _metal _Fiberglass _PolyethYlene_other(explkin)
SUBSURFACE SEWAGE D15065 Alt SYSTEM INSPECTION FORM
PART C
` SYSTEM INFORMATION (continued)
Property Address: `-i • xtJ�-�'L ��•0 �I '�-�J
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation dot required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type: ° Y� S1�.21.3� :� �.
leaching pits, number:�� ; 1
Cy
leaching chambers, number: .
leaching galleries, number:
leaching trenches, number,length:____
leaching fields, number, dimensions:
overflow cesspool, number: .
Alternative system:
Name of Technology:
Comments:
(no ,cond�tionof oil; sigvof hydrau is fu a
level of ponds ', condition
f veget ,etc)
'
CESSPOOLS: Y\
k
(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:
E
`
Materials of construction: R
Indication of groundwater:
inflow (cesspool must be pumped as part
of
Comments:
(note condition of soil, signs of hydraulic failure,
level of ponding, cohditiori of vegetation; etc.)
PRIVY:IL�'
(locate on site plan)
Materials of construction:
Dimensions:<.
Depth of solids:
Comments:
(note condition of soil, 'signs of hydraulic failure,
level of ponding, condition ibf t%egetation, etc.)
(rovis•d 04/2s/97)
sgi► e, st its
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within t (Locate where.public water supply comet into house)
' N -C3
t
cat,
f- , 40
(
► _ tall
(revised 04/25/97)
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) .
Property Address:
Owner:
Date of Inspection:
ilk
PAX&10041M'45i
si ENTERPRISE% INC6
BATESON
extavollhg - Water & Suer Litibi Se-plit gy9fthii
I ftilla Road i Andovef, Matg, M A M
q,ftle 5 Inspettloh ftepokt
property Addregg
Date of iflspectfotjt---
my report contAlhod herein do6b not d6fiNtibiltO A giiaraHti3u
Of EdEuta Usage and the tit th@ o:kIdUngi iidjjtjd�'. �i
systOM4 such koodkC 166U68 hetbolth to tfidkoiy badod upon my
ob9OtV8tlofiY f
sj and i h@reby diOdialin ahUetfief 606f it it
Of' your LiUtkent b6ptid gygtOtfii
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agl uT buTgaaw a pTag p.zeog buTuueTd agl 886T 'LT .zagwanoN uO
:9 abed
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/AS
ar-
1C\ Commonwealth of Massachusetts
City /Town of ASCEI 712DSystem Pumping Record NOV 12
Form 4 TOWN OF NORTH ANDOVER
�M
_ T E
DEP has provided this form for use by local Boards of Health. Other fo HEALTH DEPA
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, iRight side of house, Left front of house, Right front of house,
Left rear of hous ig tre r of hour Left rear of building. Right rear of building.
Address o C4
"4
Citylrowh
2. System Owner:
Name
Address (if different from location)
Cityrrowh
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State
hr't C- 06'x\� (�
Zip Code
State,�-� S— C) _ � 4 Zip Code
7
Teeie hone Number
Date 2. Quantity Pumped:
Cesspool(s) algeptic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes a No
5. Conditign Stem:
[&U
J�J
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locati re contents were disposed:
G'LYS.D n , Lowell Waste Water
of
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1