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HomeMy WebLinkAboutMiscellaneous - 1060 TURNPIKE STREET 4/30/20186A,,t MAP # 40 7 LOT PARCEL # STREET��j%�'l✓� _. ' CONST13UCT LON_APPROVA.L, HAS PLAN REVIEW FEE BEEN PAID? YES NO ^� l PLAN APPROVAL: DATE APP. BY_ DESIGNER: PLAN DATE. CONDITIONS WATER PPLY: TOWN WELL WELL PERMIT DRILLER._..,_._._____.__._..__.._..__ _._._..__._................ WELL TESTS: CHEMICAL llAIE A{'PF�UVED._.___i.......... _ rERIA I DAIE (IPPRUVED BACTERIA DATE APPROVED _^ _ COMMENTS: FORM U APPROVAL: APPROVAL TU ISSUE _ �SNU DATE ISSUED BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU .SEPTIC SYSTEM CONSTRUCTION APPROVAL YES No OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DA T*E :.._,......,._._ F w 9EPT��SYSZEM�NSIflL.�9ZT.QLI =:x •IS THE INSTALLER LICENSED? +r YES NO TYPE. CONSTRUCTION: ; N REPAIR' NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO ' CONDITIONS OF.. APPROVAL. YES NO (FROM FORM U) 1: .,ISSUANCE OF DWC PERMIT YE NO DWC PERMIT NO. 7� BEGIN INSPECTION YES N0: ' _.. EXCAVATION. INSPECTION: :NEEDED: PASSED ,,, " ' BY' :CONSTRUCTION INSPECTIONS .: ;;_'.- NEEDED: •1 t '-.AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: li BY FINAL .GRADING APPROVAL: DATE,,3 BY r' ,FINAL CONSTRUCTION APPROVAL: DATE• �/ Y Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. RECEIVED Commonwealth of Massachusetts Title 5 Official Inspection Form 11119 2016 Subsurface Sewage Disposal System Form - Not for Voluntary AssessaTgArs' OF NORTH ANDOVER HEALTH DEPARTMENT 1060 Turnpike Street Property Address Xiaoxin Yu Owner's Name North Andover MA 01845 City/Town State Zip Code 11/18/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover MA 01810 City/Town State Zip Code 978-4754786 SI -15 Telephone Number License Number B. Certification 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urthe Evaluation by the Local Approving Authority 11/18/2016 Inspec ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc - rev. 6116 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 1060 Turnpike Street Property Address Xiaoxin Yu Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 11/18/2016 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new d -box, replace section of pipes with roots, remove trees by d - box, fix pump tank cover, inspection from B.O.H., septic system now passes Title 5 Inspetion.. 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.doc • rev. 6116 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 of 17 I . gv l l,.D w G TTI E S . , W - 21999 966 61 Coe, au -r s,r. S, -r, M . N (cTe _' 22, 3' Z �;" S" - ---- - PL. M • 1-+• (bvTCEi� — ZO,�I 370 = 72 R, 00 88.9' I ZO.7' 5QD Te* ZZg•sZ -- IFwD Z. 137, C SND Te'W2 --------- I W55 F ELE 6k-El0II S G RzG = Z Zo, i Z W S,T,' au -r s,r. im PG. at. y9 BoT; Pe. - ZIL4,25, IQ D-EbX (Z") = 72 R, 00 Ovi' D -Box = z2 S, Oq 5QD Te* ZZg•sZ I mt , T'F.*-Z Z 24 88 SND Te'W2 = z Z6, SS --- - Epe.E. OV we -2A kj-D 137,9D' 31 �' � 0 1 a 4 �A ExisT►�li B Zo5 00 x'31 10.5" is'± o ZZ8 o Qvv^ T Vi SE 10" Zqy, 80 LOT'3 1 Gey, q'q I c. F (2.4t —roe, Zj5s W TELL. S vi E. h7,5A 1500 6A/-. S6Prie- TAwv- (S.T) - 1 SO0 6k, F'vHf> CHAMBE2 (PG.) ST-EE15T- (ZTT=-' I I iq ) AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN AS PREPARED FOR ATE �I7A-2CORP. P SCALE: l"= 40' ta6d G.. Lo-F#3-TveNPiKE STREET- T. M, lob -G P82.8 MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, .MASSACHUSETTS 01810 li'AR 2, / 99 TOWN OF NORTH AN'DCl,-/,` . BOARD OF HEALTH IAV s,�-; Co IZ . A Ov r s,r C H . (e7Z) -' ZZ. 3' Z�;',S L Q RC -M. F4. (o�rcEf) 37, g' Du -r D -Box Z Z S, aq 5QD Te* I ZZ d. sz IMt, T*p�*Z = -Z 24, 88 FWD T1Z Z l 37, o' = z Z& 5s TOWN OF NORTH AN'DCl,-/,` . BOARD OF HEALTH EAL,E O F klerl A ki I) IAV s,�-; = 2►�, �� Ov r s,r = 219.5LI Ilu PG. = Z► 9. L49 BaT' F'e. - ZIy125 IQ D -Box (Z'') Z 2 R, oo Du -r D -Box Z Z S, aq 5QD Te* I ZZ d. sz IMt, T*p�*Z = -Z 24, 88 15ND Tet = z Z& 5s EAL,E O F klerl A ki I) AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN I,IORI�H ANDOVER, MI{. AS PREPARED FOR GvtiyA CORP. DATE: I I-27- 98 SCALE: I"== q0' NousEw ID (00 �. Lo -F-43 -Tu¢NPIKE STL'EET- TM 107-G Rt2 8 IMERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 MQ� 2, i 9177 137.90' 31.x` LD 3 o o 'q F; �Z Exisri�L� 2 �/ •Q 1.1.F D. SID D 11, 11 C P T - ZZZS7,C��O'r / ZG i� ►5'+ Z28 - O O �* Q TErZ n C } Z�SG}IEMA m _ _ G o.o. Z �ql� 11M 10 1500 GAL, 9pf"nG TAkjV 15Oo 6AL. RUMP C}�AMBEIZ (PG.� AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN I,IORI�H ANDOVER, MI{. AS PREPARED FOR GvtiyA CORP. DATE: I I-27- 98 SCALE: I"== q0' NousEw ID (00 �. Lo -F-43 -Tu¢NPIKE STL'EET- TM 107-G Rt2 8 IMERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 MQ� 2, i 9177 _, r;} �;�� r � „ � t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIRONMENTAL Pl 'AIRS TION TITLE 5 V OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS Property Addre! Owner's Name: Owner's Addres Date of Inspectii SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Name of Inspector• (please print) --2usa Company Name: ! Mailing Address: ,z � Telephone Number:- R� VED SEP S 0 2004 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: XPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority ls Inspector's Signature:j,1,L— G Date: / O 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: MQ OZU go Ve Owner Date of Insp tiod: cl-/3 e Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D . A. System Passes: 1/ 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' _ s 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 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: NO QA]L nW f� Owner: Date of Inspec#ion: 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)(6) that the system is not functioning in a manner which will.protect public, health, safety and the environmept:: Cesspool or privy is within 50 feet of a surface water r _ 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 I.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 mustnb- attached to;,this form 3. Other: 3 Page 4 of 1 I P OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: tb(oL liar��✓��k� �' Owner• e Date of Inspecth n:_b 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 cr-Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool , 6'" Static liquid level in the distribution` box above outlet invert due to an overloaded or clogged SAS or cesspool P L --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 (,• y 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 coliform bacteria and volatile organic compomads 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.] (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 sy"sfem 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 11 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: jL&6T rnm Ko S7 - Owner: Q e Date of Ingocti n: Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes No t /~ Pumping information was provided by the owner, occupant, or Board of Health -lwere any of the system components pumped out"in the previous two weeks? 4 ✓' _ 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: Yes no %:. t 0 Existing information. for exainple�a plan at the Board of Health. F _ _ Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)) 5 P Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:)Z22)0,L) �f Owner: koilkloo Date of Inspe"ctio'n: 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): 3 -3o Number of current residents: Does residence have a garbage grinder (yes or no):),/0 Is laundry on a separate sewage system (yes or no): ✓G [if yes separate inspection required] Laundry system inspected (yes. or no): _ ► t - ` ,. Seasonal use: (yes or no):,,-. X16 Water meter readings, if available (last 2 years usage (gpd)): Sump Pump (yes or no): SIU Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: 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: Was system pumped as part of the inspection (yes or no):S 1f yes, volume pumped/51A) gallons -- How was quantity pumped determined?% �ZC�czc ,n.ie-./ Reason for pumping: C it 5 T,2v c aC ( S TYP"F 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): of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): 6 Page l of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: d 0�) Owner:4 e' Date of Inso cti BUILDING SEWER (locate onsite plan) Depth below grade: Materials of construction: _cast iron --'40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints; venting, evidence of leakage, etc.): J U T'S �s o u l� ,x/di,' -i�� �i� A0 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: "' 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: Sludge depth: `r Distance from top,of sludge to bottom of outlet tee or baffle: 9 Scum thickness:_ /, 0 Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: _ j " How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relate to outlet invert, evidence of leakage, etc.): A/ /`Je-,!= S 9!�+d T4.4 r ly a GREASE TRAP: /Acate on siteP lan) Depth below grade; _.... �, e Material of construction: - concrete _metal _fiberglass Polyethylene _other (explain): Dimensions: Scum thickness: . Distance from top of scum to top of outlet tee or baffler 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 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:lD l I U rn �)i Yp S-7, r Owner:. u Date of Inspection:` 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: , r 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: i /' Jif present must be opened)(locate on site plan) . Depth of liquid level above outlet invert:_u+ 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.): Pcf/D PUMP �/40cate CHAMBER. on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ^y { _ m t 8 Pagef9 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10llO 112L4h ,ST' Owner: n% ialj Date of Inspection: — 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: - % 4.0. 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.): CESSPOOLS: (sspool must be pumped as part of inspect ion)(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 o; t` PRIVY:(locate on site plan) condition of vegetation, etc.): Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of.ponding, condition of vegetation, etc.): 9 } ,,Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ( . !tJ rnQ;T Owner: L/ _ Date of Insp cti : — �- 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. -) r I -IL 4-0,C- _4 U 10 �� 1. iav 61 A L J")u W p h.1 #✓ . w r asp, r %3 —G. o d Tv 3,2- IF C ?'o p- r3o ;- Pagel 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' Property Address• r Owner: Ivqo/ Date of Inspie tiod: — SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water {% feet. Please indicate (check) all methods used to determine .the high ground water elevation: L""Obtained from system design plans on record - If checked, date of design plan reviewed: %#42, 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: t7 �' 'fl' k Town of North Andover, Massachusetts Form No. 1 ` NORTH BOARD OF HEALTH yE 6 OL Apt 19 �AoeCX1CeW_;p y APPLICATION FOR SITE TESTING/INSPECTION Applicant G UA) YA e040 NAME ADDRESS TELEPHONE Site Location544 T: c3 T-U,60,DIBE Engineer�� NAME ADDRESS TELEPHONE Test/Inspection Date and Time 9L % �l CH -AIRMAN, BOARD OF HEALT Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts . Form No. 1 Oy SS `Eo ib 9�OL f ! dC d/r% 19 - APPLICATION 9APPLICATION FOR SITE TESTING/INSPECTION Applicant 09UA)YA ee) NAME ADDRESS TELEPHONE Site Location 4 7- ':'; Engineer A/0/lw1 NAME ADDRESS TELEPHONE Test/Inspection Date and Time V 71`} CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Applican Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 19 q3 APPLICATION FOR SITE TESTING/INSPECTION Site Location-, W -T - Enginee NE Test/Inspection Date and Time Fee 1 CHAIRMAN, BOARD OF HEALTH Test No. _, Is_- S.S. Permit No:-D.W.C. No. C.0 Date Plbg. Permit No. BOARD OF HEALTH 146 MAIN STREET TEL. 688-9 540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: 1.4 -3 LOCATION OF SOIL TESTS: Lo j 5 Assessor's map & parcel number: IQ -C - c3 OWNER:(Sv)_yA CvY,p. TEL. NO.: 2_a7-9314-76ZZ ADDRESS: I`(O SAGO AVE, d�_Q Of -7e iAQQ B_fr1(fi4 ENGINEER: Q --i Z , TEL. NO.: q7, -f5 CERTIFIED SOIL EVALUATOR: G.)iU-i R r-1 poi= gi5�: �j r'_ - Intended use of land: residential subdivision, single family home, commercial. S►uGc>= E� H- R+--11�4%LA s (2� THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan SES VV6vwuV-,- A PPP4u03 6" F L� E_ L_)t 3. Fee of $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and ,two percolation tests are required for each septic system. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. FIELD DATA REPORT SHEET OF PROJECT t- :� 17�i/�. ' v ✓ PROJECT NO. �^ SUBCT DATE 3 O JE PREPARED BY 1 i c� J S a Cr IT / L ,,,a,,ui= -- StoneHill Environmental, Inc. M'| / �\ i. |� � || �. �. (' / `7 -4L;��,)77 . - / �- i V IN mil i I I i ! I I i I I I • I I I I 11 1- I I I I I I I I I I I I 1 i I� 1 I I I '-� - � 1 I I �• I I i' 1 I , I J1 1 I I I I I I j I I I I 1 I I I 1` Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director (978)688-9531 Mr. and Mrs. Kwon 1060 Turnpike Street North Andover, MA 01845 July 1, 1999 Dear Mr. and Mrs. Kwon, 27 Charles Street North Andover, Massachusetts 01845 Fax(978)688-9542 This correspondence is in regards to the septic system which services your property at 1060 Turnpike Street. A recent observation was made by Health Department personnel which could seriously affect the proper function and longevity of the leaching field and it's attached components. The problem observed concerns the final grading of the system. This septic system was properly installed with 12 + inches of cover in August of 1998. It appears that this cover material has since been removed, which has now exposed your distribution box and has lowered the final grade. In addition to the above mentioned reason, this change is of great concern to the Health Department due to the easy access to untreated sewage by children through the uncovered D -box. It is very important that you restore the final grade to agree with the engineered plan as soon as possible if you hope to minimize the negative impacts. A licensed installer should be hired to properly do this work or may you further harm your system. If you need a copy of the original plan, the name of the original contractor or have any additional questions please do not hesitate to call the Health Department at the number below. Sincer Z/sanFord Health Inspector CC- Sandra Starr, Health Agent File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director (978)688-9531 October 20, 1998 Mr. John Carr 33 Oak Knoll Road Methuen, MA 01844 Dear Mr. Carr: 0 Fax(978)688-9542 This letter is to notify you that you passed the North Andover Disposal Works Installer's test with a score of 84%. In addition, your disposal works construction permit for Lot 3 Turnpike Street is ready to be picked up. Please do not hesitate to call if you have any questions. Sincerely, Sandra Starr, R.S. Health Administrator S S/cjp cc: William Scott, P&CD BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 W, — ob. Town of North Andover F AORTH , OFFICE OF 3=Ottt fo e.e�OL COMMUNITY DEVELOPMENT AND SERVICES ° . A 30 School Street North Andover. Massachusetts 0184 �4 o° ATE0 WILLIAM J. SCO'17 Director August 3, 1998 Merrimack Engineering 66 Park Street Andover, MA 01801 RE: Lots 2 and 3 Turnpike Street Dear Mr. Godin: This is to inform you that the proposed plans for the sites referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Aug -03-98 08:06A Paul D. Tui -bide, PE/PLS August 3, 1998 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for Lot 2 Turnpike Street Dear Sandra, 508-465-0313 P.02 We find that the most recently submitted plans for Lot 2 Turnpike Street by Merrimack Engineering Services have been corrected of the problems outlined in our previously submitted checklist. If you have any questions or comments please feel free to contact us. Sincerely Carlton A. Brown, PE/PLS POItDi INGINEERING Civil Engineers & Land Surveyors One Harris Street Newburyport, MA 01950 (978)465-8594 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL (978)475-3555,373-5721 • FAX (978) 475-1448 • E-MAIL: merreng@aol.com July 28, 1998 Ms. Sandra Starr Board of Health Town of North Andover 120 Main Street North Andover, MA 01845 RE: Lot 3 Turnpike Street Dear Sandy: JUL 2 g In response to the Title V review performed by Port Engineering for the subject septic system design, I enclose three (3) sets of plans revised as follows: • Deed reference (Note #8). • Soil evaluation certification added. • Calculation shown for groundwater elevation at building. • Buoyancy calculations are enclosed for septic tank. • Compaction of fill and crushed stone specified beneath D -box. • Note added to profile specifying first two feet of pipes out of D -box to be level. • Pump performance curves are enclosed. • Buoyancy calculations are enclosed for pump chamber. • Orifice size for perforated piping is specified (Note #2). • Slope easement(s) are shown. Please process this information and feel free to contact me should you have any questions or comments. Very truly yours, MERRIMACK ENGINEERING SERVICES Les Godin Project Manager cd FORM 11 - SOIL EVALUATOR FORM Page 1 Date.."..✓..lc.�. Commonwealth of Massachusetts Moen{ AKLWVEP , Massachusetts •. if •t• Performed By.. .�.�................................ ............................... ..5.-x.7..-98 Witnessed By:.:::�.::::.::::�TPr..��:::.:....:::::::.�.�:.:::� ........................................................................................................ FLOwim 3 �ut� i�4 � �" T, , �qS SAc© AVoen New Construction K Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes 1 Year Published .... Publication Scale Soil Map nit ......�. Drainage Class ...C....... Soil Limitations ..................................................... .....PAX.TIOAI.4 ............ Surficial Geologic Report Available: No ❑ Yes ❑ Year Published 77777 Publication Scale GeologicMaterial (Map Unit).......' .............................. :..................................................................................................... Landform .... y_.... ! .......................................................... ................................. ..................................................... Flood Insurance Rate Map: # ZS Dqg CVOO C Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No ® Yes ❑ Within 100 year flood boundary No ® Yes ❑ Wetland Area: �, -ice �rr.�til................ National Wetland Inventory Map (map unit) ... !PP Wetlands Conservancy Program Map (map unit) ............................................................................ Current Water Resource Conditions (USGS): Month MAY.. Range : Above Normal❑ rmal ® Below Normal El (RsSut-%�D) M Other References Reviewed: U. S a HAP S *1 Wz FOMI It - SOIL EVALUATOR FORM Page 2 On-site Review Z M Weather ...�C ...5'c,ri.l....c� Deep Hole Number ...�. Date:'.7-77i8 Time:... »..... . Location(identify on site plan)...... -... T......sww..................................................................................................................................... Land Use ..�I....ER �.,... ....... Slope ...... Surface Stones .... MSA.MIT M, ............... :.............................................. Vegetation...f~G�'3�rl?...........U.+4........S.T�.............................................................:............................................................... Landform....... 1"1.i.1.l.,.t:......................................................................................................................................................................................................... Position on landscape (sketch.on the back)..........P40.q..................................................................................................................... Distances from: Open Water Body ....I00t feet Drainage way.... feet Possible Wet Area ...10a t feet Property Line ....>iQ.... feet Drinking Water Well .41A ..... feet Other ......................................... DEEP OBSERVATION HOLE LOU Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munselll Soil Mottling Other (Std ton %Gravlders, ,stencyStones r,>"— 1z" —aaFnce: s-r1zrP� lZ"-��j" � SAw 2�sYs/y 7.syQs/� r,r�ss►,�� Fic�t� � !-op t j SY Z P(X4X-,S aF r-Q� A &J -e or- "Aly SHuby LOAM. 10% �P�4V bEPt+f of 151 14L VAQ4S NAlsivr- S V, FZ A0u-- SAWD SY�E 3 00 1Z5 eZ 9A Ohf Z,Sy5�1-I ° 15";° r�nss►vr`, �� Parent Material (geologic) ......�� (.l L...,L. .......C'�r�. ........................... Depth to Bedrock: U./A .............. u Death to Groundwater: Standing Water in the Hole:%P�k.... Weeping from Pit Face:v..�...� Estimated Seasonal High Ground Water: i'2 ,. S'Z I L0r,3 FORM 11 - SOIL EVALUATOR FORM Page 3 I-Mrll I 101 . WMWOO Method Used: ❑ Depth observed standing in observation hole ................... inches ❑ Depth weeping from side of observation hole inches 56 Depth to soil mottles tZ.4.5Z inches ❑ Ground water adjustment feet Index Well Number ... Reading Date Index well level ................... Adjustment factor :... ''"- Adjusted ground water level ........................................................ Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on -330--6 (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature �� Date 4�- e-qg )-0:r, 3 FORM 12 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS NoM A"WV6Z , Massachusetts Site Passed Site Failed F1 , ............... . ................................................................................................................ Performed By: 615 S - Witnessed By: FLjIL Comments: SO� ....... pi, � W;� . 1. 9S_ 6.1 61L .4 ..... I ...... , ... ............................. ... .......... Percolation Test Date:..... 5--Z7716 Time:* ..... ............ Observation Hole # Depth of Perc "t q3" Start Pre-soak -1 ('Z7 End Pre-soak Time at 12" Time at 9" IZ� 1G Time at 6" Time (9"-6") Rate Min./Inch Site Passed Site Failed F1 , ............... . ................................................................................................................ Performed By: 615 S - Witnessed By: FLjIL Comments: SO� ....... pi, � W;� . 1. 9S_ 6.1 61L .4 ..... I ...... , ... ............................. ... .......... Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover, Massachusetts 01845 WILLIAM J. SCOT -I' Director Merrimack Engineering 66 Park Street Andover, MA 01801 RE: Lots 2 and 3 Turnpike Street Dear Mr. Godin: July 24, 1998 ORTM This is to inform you that the proposed plans for the sites referenced above have been disapproved for the reasons below. 1. No deed references are shown on either plan. 15.220(3) 2. Plans do not contain designer's certification statement. 3. Basement floors appear to be less than 1' above groundwater elevation. NA 5.04 4. Bouyancy calcs for septic tanks missing. 15.221(8) 5. No compaction of soil fill under D -boxes specified. 15.221(2) 6. No stone specified beneath D -boxes. 15.221(2) 7. Pipe from D -boxes not specified level for first two feet. 15.232(3) 8. Pump performance curves not provided for pump chambers. 15.220(4)(r) 9. Bouyancy calcs not provided for chambers. 15.221(8)(a) 10. On Lot 3 fill area extends over property line. Slope easement specified but not shown. 15.255(2) Please be aware that all revision submittals must be accompanied with a $45.00 fee. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator CONSERVATION - (978) 688 9530 - HEALTH - (978) 688-9540 - PLANNING - (978) 688-9535 *BUILDINGOFFICE - (978) 688-9545 - *ZONING BOARD OF APPEALS - (978) 688-9541 0 *146 MAIN STREET Jul -23-98 09:53A Paul D. Turbide, PE/PLS e July 23, 1998 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for Lot 3 Turnpike Street Dear Sandra, buts-4bb-u-s1.3 r v3 Enclosed find the "Checklist for North Andover Septic System Plans" for the above- mentioned site. The following is a list of all the `Problem' areas and deficiencies Port Engineering has found. General Information • No deed references are shown on the plan. 220(3) • Plan does not contain designer's certification statement. • Basement floor appears to be less than 1' above groundwater elevation. NA 5.04 Septic Tank • Buoyancy calcs have not been provided. 221(8) Distribution Box • No soil compaction of fill is specified below d -box. 221(2) • No stone is specified beneath the d -box. 221(2) • Sewer is not laid level for first two feet. 232(3) (c) PuMp Chamber 1 o Pump performance curves have not been provided. 220(4Xr) • Buoyancy calcs have not been provided. 221(8)(a) PODT Leachine Facilitit Iy fNGIN�E�I�G ° No orifice size is specified for the system. 251(8) • Fill area extends over property line. A slope easement has been called for but has not been shown. 255(2) Civil Engineers & Land Surveyors If you have any questions or comments please feel free to contact us. One Harris Street Newburyport, MA 01950 Sincerely (978) 465-8594 UUITM A. Brown, F"L3 LOT- 3 'FL'o`lAuc y eAC.000TOMl FO -V- ISbd:' 6AL , SF -CF- TA)Ld:L L✓A Tf4L = Co2 , - � /6. F. cou c aeTs = 13o w C . f:r. �1✓iG� 1 of Th),kI6 f5m? _ L = I 0 1 &';K lo' 33 x W,(Y7 IF) -(o S = O .3 3'x 63 X Bor i 3v c t'. Ig18c-f VvPjA -c t Fofe-,r— = YoCvt-%S of TA ii13tE r.a�xI_sr,u.C, .G.fAoC - 38" l J Z [. a V�L�� IC &W W..T', - 2t�1,(�-ZIS) �xro'�=IS�c.F BR JONA �I fd(LC = I�Co e_F. x GZ, ic. r. 97s -o �' f -M 0 - O'X 6, 4 10) 6;0 if F x 130' /e. F, —9syN# kJV Foo,gAu6y L'�1.Culv�rtotilS TDe. is- 6AL , L✓ATeZ7 _ (oZ,� # /C.F: co) -_(e, ar- re = 13o W G - F'. 1✓�G1� 1 of TNIGp x �O�x i0' DoT"= 0.33�x G�x !o� , S1 ops - a.33 y,G7 x oS= 0.33x 4,63 x5,33 .Bor,= Li" -IVP76" 01441.5' y„ x 3o c. F. (9,8c,r c. r. x i 3 ft/C.F. =95�1� �► E R�b�t�u 1 01V,� OF TA) -V- SEtvw wjjT!!gL lig WAS 5 F,L = xISpUu GRAoc _38 " ►� A S_oT.9uI� EL -T,61-fIC. 9f%w,4j W,."1", _ (21��$-Z�s,o) (��x►o 1. (pg cl= il \ \ l a ;.: SLJONA Li (L 0 1` Svi3`T(t� e r doe- Ito' b QL),.o Ra -111A W"i6l t c� -TA �� �,o xCo x C I=- C, C, F-. x (30 / e +6,7So'*(f) 3-7S6�* j ) -70°0F �) _ _ 1y 3��1 V.l 0 '�flL.Gt1 ST Jf Town of North Andover NORTH OFFICE OF 3� 10 `•' ��o COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street + North Andover, Massachusetts 01845 0 WU JAM J. SCOTT Director April 10, 1997 Mr. King Weinstein Gunya Corporation 32 Saco Ave. Old Orchard Beach, ME 04644 Fax# (207) 934-1566 Dear Mr. Weinstein: This letter concerns Lots 2 & 3 Turnpike Street, North Andover and the recent problems concerning contaminated fill placed on the lots. I have been by these lots and have observed the stockpiles of fill and brush and apparent excavation over various areas of the lots. Much of this activity appears to be in the areas of the proposed septic systems. Because of this, the approvals for proposed septic systems have been suspended until the Design Engineer has located all stockpiles, brushpiles and changes in elevations and submitted them overlaid on septic plans to the Board of Health. Please note that if there has seen sufficient deformation of the site the septic approvals may be withdrawn. Please call the office if you have any questions. Sincerely, Sandra Starr, R.S., Health Administrator SS/cjp cc: Michael Howard, Conservation Admin. Wm. Scott, Director, P&CD BOH File 9ne,Rn T APPEALS 69R-9541 BIS Y)IN ? 409..9�i5 ••�• rr•.\'_^ �_' ?'..E AITF 6w9W MERRIMACK ENGINEERING SERVICES INC. Engineers • Surveyors • Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 (508) 475-3555 FAX (508) 475-1448 OF Wo, A1--(06\CE(2. > WE ARE SENDING YOU Shop drawings Copy of letter COPIES DATE q I-Zb-`t s Page No. of Pages LETTER OF TRANSMITTAL JOB NUMBER I DATE ATTENTION RE: �-V t I J Attached — Under separate cover via Prints — Plans _ Specifications Change order _ Other: NUMBER I DESCRIPTION PCcA 1...( OF p S. AS 1-vr sf�D COPY TO It enclosures are not as noted, please notify us at once. Resubmit — Submit Return the following items. — Samples rtmv OF NORTH ANDOVER/ BOARD OF HEALTH OCT 4 1995 copies for approval copies for distribution corrected prints PRINTS RETURNED AFTER LOAN TO US SIGNED -" O� THESE ARE TRANSMITTED as checked below: For approval Approved as submitted > _ For your use Approved as noted As requested _ Returned for corrections _ For review and comment _ Other FOR BIDS DUE/DATE: REMARKS siq k, per/ - 1.tE;�-O TrST P tiS A (lam COPY TO It enclosures are not as noted, please notify us at once. Resubmit — Submit Return the following items. — Samples rtmv OF NORTH ANDOVER/ BOARD OF HEALTH OCT 4 1995 copies for approval copies for distribution corrected prints PRINTS RETURNED AFTER LOAN TO US SIGNED -" O� A'11' e1 PC 4 Town of North AndoverNORTH 3?0yi trio 6 0 OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES p - s a 146 Main Street North Andover, Massachusetts 01845 4SSq�""SEt (508) 688-9533 VIOLATION NOTICE Issued from: Issued to: Date: NORTH ANDOVER CONSERVATION COMMISSION GUNYA CORP./KING WEINSTEIN/C.P.MCDONOUGH/ALL SUBCONTRACTORS FEBRUARY 27, 1997 D.E.P. No. 242-705 Location/Property- LOT 3 TURNPIKE STREET, N.ANDOVER, MA.01845 The North Andover Conservation Commission has determined that the activity described below is in violation of the Massachusetts Wetlands Protection Act. (M.G.L. Ch. 131, Sec. 40) and/or the Town of North Andover Wetlands Protection Bylaw. Extent and Type of Activity: REFER TO ENFORCEMENT ORDER If this violation is not immediately addressed as required below, an Enforcement Order will be issued, which may include a stop work order, which may be followed by,legal action. Required Action: REFER TO ENFORCEMENT ORDER Questions concerning this violation notice should be directed to the North Andover Conservation Office, Town Hall Annex, 146 Main Street, or by call' (508) 688-9530. Signature: i BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover NORTH OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street •,� North Andover, Massachusetts 01845 -Too �. WILLIAM J. SCOTT 9SSACHU Director Dep # 242-705 FEBRUARY 27, 1997 1. Stockpiled, non -indigenous soils have been sampled, and are considered potentially hazardous materials . (Ex. building debris observed in stockpiles, pipes, bricks) A strange odor was also observed on site. 2. The silt fence was installed improperly and inadequately. Haybales are not staked. 3. There is soil infiltration taking place in the resource area. 4. There are cut trees that have been dumped in the resource area. 5. Illegal stump dumping. 6. As asked in a site inspection conducted on February 11, 1997, wetland flags were not re -flagged. 7. As asked in a site inspection conducted on February 11, 1997, failure to remove original silt fence in resource area. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORTP# BOARD OF HEALTH ° 120 MAIN STREET TEL. 682-6483 CHU �NORTH ANDOVER, MASS. 01845 Ext23 August 9, 1994 Re: Lot #3 Turnpike Street To Whom it May Concern: This is to inform you that the proposed plans for site referenced above have been disapproved for the following reasons: 1) Insufficient testing in system area. 2) Please put benchmark in system area on site plan. 3) What are dimensions of reserve area? More tests needed here. 4) No foundation drain. 5) Please show limit of system excavation on site plan. 6) System must be vented. 7) Please add thrust block at pipe angle prior to D - Box. 8) Please indicate schedule 40 pipe in leach area. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out.this section***************** 5a� 37a -&'1rd APPLICANT: 11,06GGJ2 i �! 5 i �� c- Phone X07 `� 3 y- 7600 LOCATION: Assessor's Map Number /0 7-C Parcel 7 Subdivision 1/XA Lot(s) --� Street �-� t St. Number�� v V ************************Official Use Only************************ RECOMMENDATIONS OF WN GENTS: Conservation Administrator Comments Y,_�� h u& W Town Planner Comments Food Inspectoorr-Health Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - -eevt7lwater connections f',0�45_514 !SIV - driveway permit Fire Departments"k Received by Building Inspector Date DATE o2 9 ol Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEEPERMIT # DATE RECEIVED���/ APPLICANT ASSESSOR'S MAP 16AG ADDRESS PARCEL # —' LOT # -- STREET 7'U�r//,�/6T' �J✓' `� ENGINEER ADDRESS PLAN DATE G 17 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED y DI�� �"-N 5 UT �/G i��(J T 7`�S�"/'r/6 /� S —POT ANG //M ✓a %c l 5 j/STCM � i� 6,ti p V6 -AJ Tis ,S 3 y;5 TeM �X � .9 V"9 T/6�v 7, --PL6�9s6- PPD T/�vST ��oc @�/ PLAN REVIEW CHECKLIST ADDRESS 3 To ,L-6 5! ENGINEER ,%l& GENERAL 3 COPIES•. STAMP LOCUS NORTH ARROW 1—� SCALE ? CONTOURS ----'PROFILE(/ SECTION BENCHMARK SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER/ WELLS & WETLANDS WATERSHED?A/0 DRIVEWAY (r (Eley) WATER LINE FDN DRAIN SCH40,a�- TESTS CURRENT? /99�,3 SEPTIC TANK MIN 150OG.17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR 4,'� MANHOLE TO GRADE d,--- ELEV GW D -BOX SIZE `j # LINES a FIRST 2' LEVEL STATEMENT INLET a, 8.9 - OUTLET g (2" OR .17 FT) TEE REQ'D? %,S LEACHING MIN 660 GPD? RESERVE AREA --' 4' FROM PRIMARY? --' 2% SLOPE 100' TO WETLANDS✓ 100' TO WELLS 1-1X 4' TO S.H.GW_L,,,::f- 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP v 4' PERM. SOIL BELOW FACILITY MIN 12" COVERL/ FILL? 1, (25' if above natural elev; 101if below) BREAKOUT MET?,-,--' TRENCHES b66&b MIN 660 gpdLx SLOPE (min .005 or 611/1001)- � - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 6') C/ IS RESERVE BETWEEN TRENCHES?A/D IN FILL?v"' MUST BE 10' MIN.L--4" PEA STONE?,2� BOT W X LDNG�0 + SIDE PA- X LDNG_& = TOT (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright 0 1993 by S.L. Stan 5 Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 N'l AU 19—iL DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant K 0A%y/2 C-bkP6,f gr16A1 Test No Site Location l � 3 �U C�C� .R(A Reference Plans and Specs DA Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH tro Fee ^ Site System Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH iD .-DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant T Test No /'% ?� .. t- Site Location L-? / 3 / bllz-I1P- Reference Plans and Specs. L°`'��/,'/J���.�'�� �� �-�' 1 ,;..� �43 ,/3 ENGINEER' SIGN DATE Permission is granted for an individual soil absoprtion sewage disposal system to be installed in accordance with regulations of the State and the Board of Health. Fee f `BOARD OF I-EALTH r Site System Permit No. ; LOCATION: NEW PLANS: REVISED PLANS: SEPTIC PLAN SUBMITTALS YES YES \l SITE EVALUATION FORMS INCLUDED: DATE: DESIGN ENGINEER: $125.00/Plan $ 45.00/Plan r YES NO DATE TO CONSULTANT: �/ %/ %ff When the submission is all in place, route to the Health Secretary SEPTIC PLAN SUBMITTALS LOCATION: l ©"T7� '-fu F_j o �. z7iy_r_ f— i o - 6 7z; 3 NEW PLANS: $125.00/Plan REVISED PLANS: YES $ 45.00/Plan DATE: - �(- DESIGNENGINEER: herZUAAGK��rC-ri�.r . �LiuG► � -€L�rc S DATE TO CONSULTANT: 7117hA When the submission is all in place, route to the Health Secretary n t9 A M V � OQ N C" n � � �. • {�-► y Z tr� i J - � z m Oo D a o c a O r Q 3 O 00 t X A s vP - 01n o D Nz A Z 0 :3 v d ( = iD M X D a10 w D '` O 37 S C1 o a z a V o m. c x 47 d m m a * oCY 3 Q z o fi W i APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER: SIGNATURE: �_� TELEPHONE# CH NE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes 1Y No Yes l/r No Floor Plans? Ye`s ' No ,1 �C��` Approval (C� Date: /U/ U TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 3/3/99 This is to certify that the individual subsurface disposal system constructed ( X ) or repaired ( ) by John Carr at 1060 (lot 3) Turnpike Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # dated 8/3/98 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersiped hereby oertify that the Sewage Disposal System ()() consaluded; ( ) repaired; by locatedat # l oho Tues P� �l" T t jt o 8-c rz was Wtallod in oontbrmance.widi the North Andover Board of Health approved p* System OWc DeAp Fa:nodt # 10` 9 , dated Nor 23, a98 , with an.approved design flow of, .gallons per dry. - Ilematerials used were in conformance with those specified on the approved plan; the system was ed in accordance with the provisions of 310 CMR 15.000, Tile 5 and local regulateons, end ,t h al pa ft agrees svbstawdly with the approved plain. All work is -accurately represented on the As -baht which has ban submitted to die Board of Health. Installer: Lie. #: P W / Date: 3 _I —17 D Engineer. c C Date: Md4 ek /7,71 1.loTE� F'iMAL 6EANV4 J CoAH To Br,— PrPmotzt"teD WHEN WIEl ATHERZ- PE2t--71TS r 0 EM4 rl s•, ' '\ uj z � co a� c c � o ` Q • C N O C ` `yC p 'O �0 H Z Oc 1LE= OC,() �� :cam �'•O o 0 CJ CM � CD a J. m y W Q1 r./ -COZ y p C o U E y CD m E" m o :nem.: m y m ; er ` .0 C W M--•1 C O Q 'fl d. co O f m t: m \: 0 0 .>Z p ..; Cc �C o C Ha Q m c o = as :moo N H o npH 03 Co o W G � .. c y at c Z LU m om.c g y o_ p • O 2 R y0 O �- = ,am , Lw� O U 2 O 2 ,v C4 C� C L O G V Z 0 0 y CD cm D � �o y p 'C CO) CD •� .FE m m CL I.—a=-+ co � � L M o a ME CMa C O +_•' � �V CL CD C CD CL V CO) C !C •C C CO) 0 x �: � � � CIO) co a W � 44 w uj z � co a� c c � o ` Q • C N O C ` `yC p 'O �0 H Z Oc 1LE= OC,() �� :cam �'•O o 0 CJ CM � CD a J. m y W Q1 r./ -COZ y p C o U E y CD m E" m o :nem.: m y m ; er ` .0 C W M--•1 C O Q 'fl d. co O f m t: m \: 0 0 .>Z p ..; Cc �C o C Ha Q m c o = as :moo N H o npH 03 Co o W G � .. c y at c Z LU m om.c g y o_ p • O 2 R y0 O �- = ,am , Lw� O U 2 O 2 ,v C4 C� C L O G V Z 0 0 y CD cm D � �o y p 'C CO) CD •� .FE m m CL I.—a=-+ co � � L M o a ME CMa C O +_•' � �V CL CD C CD CL V CO) C !C •C C CO) 0 4 L/ AS -BUILT CIIECKLIS'T LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS -a. FROM SEPTIC TANK —b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FUN ELEVATION LOCATIONS OFA, , V� WAN 150' OF SYSTEM WETGA�(1] �Notjij LOCATION OF WATER, ELEG IC LINES,� ABLE ) VE2 FF�A� DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE (©i4 ceor.) IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW 4 I✓1NAL Gwtp►ul1 JLvAt'1 �, S��,DrR(!� 7a BE FINAL CONTOURS PErz�tz��cA wr�eN wEttN�✓✓L PEZ�iTS LOCATION & ELEVATION OF BENCHMARK USED (-rop Fiuo�Tu. vs�) LOCUS PLAN (915r— /--bDRE S'S ) �cY,h� l prorldrd )hlrYlo�ln iol � � o v;' Ic; of o� l:bnullod Io thi locl! 6 A' Faclllty In(orm��lon. . y�>�', r�•,� ; $�' 519,^1 l Lj Nri1, ,',(' IIIA115?6`IpuUonJ • �4^o*n .. umping',�a�ord /� I,' 0110 91 pumping,; aCa"CC 01 � I + (dOJC,�fDO JW?, Yo) Q No 1/,.• ;'7 111;,C,Qrid�yon 9G9Yjml,,�r.,, 'li,•,.r,l�i~Yl ' 'I 1,'1'11 PU,�p!Id;BY' Olt I ���jj 91Nlv4(y�,r,f,l, poY/do p 11,11rla pD�9Ya�a1141orm �,nl,�nain • , .. , I ,,;, ,. 1111, E 1 � opl!C Ton.7 , IIy01 nOfI.C:OdndO? RECEIVED TOWN OF NOR1' ANDOVER C� SYSTEM PTP' G RECORD SYSTEM OWNER & ADDRESS �Y 9 y� Ale DATE OF PUMPING: YSTEM LOCATION pIaANT1TY PUMPED: �-:L V PWL: NU Yf;S,, ... $tlpuc Tank: NO. _ YES NA ruRb OF SERVICE: Kuu'CI.Nk_..._.L_l6MER0hN(')' UbSERVA,CIUNS, --' GOOD CONDITION FULL 'I'U COVER HEAVY OREAME BAMBS IN PLACL ROOTS _ LRACKFIELD RUNBACK EXCESSIVE SOLIDS— FLOODED SOLID CARRYOVER, Tw_ OTHER EXPLAIN , systom Pumpcd by WMMENTS. (_'UN UEN I'S I'KANSFIw MD 1.0 : / ',Y\�,,Y•� �1 li!i�J•7 G�YY: f{IY,'}':, �N 1 l.l! _ '{ 1. VIVO!? l 't ( r 17 1 5 1, (qtr '° tr�i ydli --•--w.+—...::...�.�,..._:....__...-- ' X��•"ji r J� � t 1 t•�t v }' ` r� ! Y''J ,. f ' 1 s, , (Y 1 Sfi r.�Ify {7� Q[�i w ti Y r 1 } I ,�+1 �' S u �Ir�ft 4` v�jr 1 6 )j {'l,y''3, �•v'J��'��' rit'%t� i` `a • i.. t VMS r1,1Ai17+f{Ii;J;71 ;,•) bf" Y (F,� 4 1'YI �� , ! n '�i Iy ' •(tY f t71( +1, „ I. L t{,�;.lilrf.'i�,•�^'i1,F.�(1t/i'�wj"., �U:�'It1�•':ly 7 1 • I `' ,!,. ,5 t}1 )7.1H'rx.rA{I..�I•VJl. l�h1 I�l i,l '�!LL•� 1 '1 ' ) + .J f lr. ,,J il�t^.'Ir,.,,'4'i�';I� •! 4 1t ,'t',,,.. ,, -. ' ,v• r t' t/i;.%'. ;•• .iar�: ist 1 may, OF • " "..:. — :�.< i. tiJ y t 1 .V',••l I.1 1 j� � 73rd fly t .t Jil.r.�4y� `. 1. � O:R�'� �� �•p 0 V Rs �t,^�.: �•r: ''!•".' �♦ .. .. syr• -AD D� CSS; S Y S T C M L O C A T r (ez�m le'� t ron Qv� /ATM • OW '+: :: �, .:j .•1'� :i.ktd's' .{•.1;7V ,r4. /r > l its dlf,`�l ' , •'l .Yrt rlt -ire"(:/''y�_.Jy^,] . { ° F�klx''•', t�r. ,,•� ,y it i��'{C�i , ,, ' v -'�, �r•'h''1', :i ('" ` ,• ! r , .. . 1 7 I' .(, j + ry4 ,r`11 �� lo- r r )w:..' t. •�,t'!(7 t . •�; .. � ..• .. ,' 1.,• s• C; l h'••'(Q11,Ai)�•, 1`tF��;,'..rti: ,'l. _ ' '., ..,�_.. •� ;�;,.:V .'1 I�D•��. ! JS'4 r�r; `s K /1 ..; r.�.. :. .•.7 .:i•a: L,•:!•;., •; . JiJ.P;Q;.•I:;.,. QUANTITY f'UMp ' C0^ 1ii,,.��tr?J� ��sJ •!,)1 � s v ' .' .. "i'� + ':'��':. d7, .'. � •' �.:. : -. 1. _'. � , ` c'•I•.�.>I'UUL,'�NO� �' � ��S � � � S�E('TICTaNK , '�,�,1�•:.;.�Jlvtrt 1.Ji1'+'J!'ylri,i� b::�t:�?�.n �:: +• �aTU 0 SES„ ,i .. •.: • 17 KE; F YICE;'�'ROUTINE,�+-/�!f�y/�/I//J�.r•EMERCEf�`CY W. LI 41x'1 U•COY li I1' 1 '- .;.`� �1�;.���.���rlr��;�Y�.oK:��;'�s��,,rr,t, ...... • ,;�g���FCLsI IN acIn EA-CH FI C L D R UN U A J ::CXGCS.SIY&ML"I.a FGO,O•DED' __— ilj.y,CA;R�C;"Y'O.Y.'4R' R`;.(EXf�IA•I�j 'r;r p 'v , rrt ' 1 ' 4C; , , .•, •^+'^!gra I t • , .___ rIR�+ ,l �•{ { hi " �i �r�:ti: •,,.,;.fit. '1 ) )..1a• r , ,( ','1ri 'WJ r�jYi\ Y�i �'f• " l, +/ia•J..v J •ii,r ,Y'.I i+r!'1�' /,,, �-. .S,i `,.}i . � ,iii �.� .s,Fyr,� +t,�. ��•� �I •(,.r'•' ,• IJ;, �.,:...1'F,,;,r;'`': t:. .;: '.x." , r• �• x,p '7-4Fj:f ;t�„'Lr�, l7, ''il,,t': ':�%.: (r,:;'•.1 , ,.'� r� �:J •i' • ., 7w4�y;t !.� ;d.I ) t�.� iW 4 i � J i ri-}1r, ( ''' L12L .•.'... ,••, , ci; i.:+�..,$)��t; �l r f�i �}rl{ �' ,t�•��rV r � .l,t r, s , � ( 'i;j'. 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" r '%�i t f�{,i.• 11'���!�: ;t•J Y.)rlrr '�; v'r Z; ,; t •'f;":., .. r r t '} i d,'. 1 �ri yr J Ht, f Ivb rV.��' rEl; ti:IlY' v 1. • ��' + . •t t1J!!r i1: �4r Fi�)'r i�i�It 1�(j.1:•i :'i rr,••. •. � .. � . - -. .r tiy.:C''/i+rfi'( i����.iY;:✓;i'{'S�%'it:�j(.tiJj(i3�A'�.�1i:S�%�Ji fir; '.i :',,:::.. p,� :'i:�"`�ai .. . l l 1 C. ,�i /,'7',+1 {! / Yii"S tY `}•�' 11 l � , i.�+'ir:Yt;;�'�::irr,l��•.�it'i!w:,S�iFl,l ii'":!i �>i;!!i 17V•: yi,; �,):, .1.: .. .. System Pumping Record B. Certification 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 timeof the-in,spection.. 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-puTsuant-to Section 15.340 of Title 5 (310 CMR 15.000). The system: t.4 d Passes ❑ Conditionally Passes; . }vsr:❑,Tail's >, ❑ Needs Further Evaluation by the Local Approving Authority l d Zpes Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of.Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Mr?('T--')9M0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessm IIyNlO6a X060 rrhq i (-e 9+ H ro erty A dress Owner information is ner's Name required for 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 SZ)- G� way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the � � � D' Q computer, use only the tab keyto move your 1. Inspector: j U r ' I D U cursor - do not use the return key. Name of Inspector Q J l _ S� �. �'4 � t VQ Company Name gun Company Address Lo1G5�U N Cityrrown State 0/R7� Zip Code 529! Telephone Number License Number B. Certification 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 timeof the-in,spection.. 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-puTsuant-to Section 15.340 of Title 5 (310 CMR 15.000). The system: t.4 d Passes ❑ Conditionally Passes; . }vsr:❑,Tail's >, ❑ Needs Further Evaluation by the Local Approving Authority l d Zpes Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of.Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 M Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A \ 1b60 I�rv4�. Property Address Owner's Name Cityfrown B. Certification (cont.) State Zip Code Date of Inspection 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: U A L /DU B) System Conditionally Passes: 4401- 13) 40A ❑ 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 he following statyements. If "not determined, " please explain. The septic tank is metal and over 20 years old* or the se is tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or filtration or tank failure is imminent. System will pass inspection if the existing tank is replaced a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if i s structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is les,p1than 20 years old is available. ❑ Y ❑ N ❑ N[),�Explain below): t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 2 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 D 6 D Property Address Owner's Name City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.); ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N/ND Explain below): El obstruction is removed El ElExplain below): ❑ distribution box is leveled or replaced ❑ Y ❑A ❑ ND (Explain below): ❑ The System required pumping more th 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with a roval of the Board of Health): ❑ broken pipe(s) are replac ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remove ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the oard of Health in order to determine if the system is failing to protect public health, safety or a environment. 1. System will pass unless Board of Health ermines in accordance with 310 CMR 15.303(1)(b) that the system is not functio ng in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is ❑ Cesspool or privy is feet of a surface water .50 feet of a bordering vegetated wetland or a salt march 15ins • 09/08 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 obo-ry Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 t SAS is within 100 feet of a surface water supply or tributary to a surface waters ply. ❑ The system has a septic tank and SAS and the SAS is within one 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is hin 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the S 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 an sis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the prese ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no of r 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 ❑ R Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ;0or clogged SAS.or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins - 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 4 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments I a �0 U� Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection Yes No ElLJ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 2f 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. ❑ 5� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ d Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 2�' 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.] ❑ P� This 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 "Zne""f th following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 40kiing water supply the system is within20surface drinking water supply ❑ ❑ the system is to ed in a nitrogen sensitive area (Interim Wellhead Protection Area - IWP r a mapped Zone II of a public water supply well If you have answered "yeAK6 any question in Section E the system is condidered a significant threat, or answered "yes" in ction D above the large system has failed. The owner or operator of any large system considere a significant threat under Section E or failed under Section D shall upgrade the system in accer8iance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 5 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 10 �-of- Property Address Owner's Name City/Town C Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No d❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Rf 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? 2 ❑ 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? d ❑ 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? This size and location of the Soil Absorption System (SAS) on the site has been determined based on: �/ E ❑ 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): ��6hy t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 6 of 117 a Owner Information is required for every page. 15 X5.09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 06 U(4 k e,. Property Address Owner's Name City/Town State Zip Code Date of Inspection D. System Information Description: K� �� n Number of current residents:_ Does residence have a garbage grinder? ❑ Yes 12 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? N/A ❑ Yes ❑ No Seasonal use? ❑ Yes d No Water meter readings, if available (last 2 years usage (gpd)):' Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: e ` I \ r, v i -Q a - Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/s/Titisystem? ftt Grease trap present? Industrial waste holding tank present Non-sanitary waste discharged to the Water meter readings, if available: Gallons per day (gpd) ❑ . Yes IJ No yxlS Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 7 of 17 I Lff: 1 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n6 b U S-� �--v, Property Address Owner's Name City/Town State Zip Code Date of D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: f / Source of information: N Was system pumped as part of the inspection? ❑ Yes 2 No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons /V/ /,i -- 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): 161ns • 09/00 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 8 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 Property Address Owner's Name Cityfrown D. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: B Were sewage odors detected when arriving at the site? ❑ Yes [ "No Building Sewer (locate on site plan): Depth below grade: ' feet Material of construction: ❑ cast iron 2 40 PVC ❑ other (explain) �f Distance from private water supply well or suction line: AU feet Comments (on condition ofjoints,-venting, evidence of leakage, etc.): A)J l L 611 10� 5lerV..ed Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal If tank is metal, list age: i,a feet ❑ fiberglass ❑ polyethylene ❑ other (explain) NIA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions:/ S �j (j �j--�� fD! x, -,*' X q Sludge depth 15ins • 09106 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 9 of 17 Owner Information is required for every page. t5ins - 09/08 Commpnwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments lo6b U� �S Property Address Owner's Name City/Town D. System Information (cont.) Septic Tank (cont.) State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle a .4 i 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 1,0 1 f� How were dimensions determined? SU P Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I 1 Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ Dimensions: Scum thickness Distance from top of scum to top/bf outlet tee or baffle feet ❑ polyethylene ❑ other (explain) Distance from bottom of scurdto bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 10 of 17 a Owner Information is required for every page. t5ins • 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name 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.): 5�2---I)rtNJIave "PCA i k Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: _ Date Comments (conditionalarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 11 of 17 w Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments O6d"ror ProDertv Address Owner's Name City/Town D. System Information (cont.) State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 01 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.): Pump Chamber (locate on site plan): Pumps in working order: Ll Yes ❑ No Alarms in working order: LTJ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: (t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 12 of 17 a Owner Information is required for every page. (t5ins • 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o60-ruf n ) c.e fi Property Address Owner's Name City/Town D. System Information (cont.) Type: State Zip Code Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: C S 7 ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate site plan): Number and configuration Depth - top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 13 of 17 �M Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /0�6 of e� Property Address Owner's Name City/Town D. System Information (cont.) Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ( I L l K)r)ttirAICC41 lb -A d� Gtr IUY� 5e Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hyI'raulic failure, level of ponding, condition of vegetation, etc.): ; (t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 14 of 17 MOORE o Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments DI60 el— 0 f ii roperty Address Owner's Name City/Town D. System Information (cont.) State Zip Code Date of Inspection Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: d hand -sketch in the area below ❑ drawing attached separately 05ins • 09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 15 of 117 0 �M Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments b� 0 -rc),r ProDertv Address Owner's Name City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar ✓ ❑ Shallow wells Estimated depth to high ground water: State Zip Code feet Date of Inspection Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: L�— atfe ❑ 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: Before filling this Inspection Report, please see Report Completeness Checklist on next page. (t5ins - 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 16 of 17 a wti Owner Information is required for every page. CommonweAlth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 106orurh-VI L to 5t Address Owner's Name City/Town State Zip Code Date of Inspection E. Report Completeness Checklist dInspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information - Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file T5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Property Address Xiaoxin Yu Owner Owner's Name information is North Andover required for every page. City/Town Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. MA 01845 State Zip Code ®,e �U16 7/8/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. ; A. General Information [a_"'akP SC-0ail, OLU 1. Inspector: �L �� `�� jP"" T 6 �'X' �V13 Neil J. Bateson z a C Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State SI 15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ❑ Fails ® N ds urther Evaluation by the Local Approving Authority 7/8/2016 Inspe o?s S nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing. this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner Owner's Name information is North Andover MA 01845 7/8/2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 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 1060 Turnpike Street Property Address Xiaoxin Yu Owner Owner's Name information is North Andover MA 01845 required for every page. City/Town State Zip Code B. Certification (cont.) 7/8/2016 Date of Inspection ❑ 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 - 3113 Tide 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner's Name North Andover MA 01845 7/8/2016 Cityr town State Zip Code pate of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 -box full of tree roots, broken pipe fitting into d -box, pump chamber riser cover 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 'h day flow t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 4 of 17 ❑ ® 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 • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System •Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. CitylTown 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 • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System •Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner Owner's Name information is North Andover required for every page. Cityrrown C. Checklist MA 01845 State Zip Code 7/8/2016 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ ® ❑ ® ❑ Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of -17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street D. System Information Description: Number of current residents: MA 01845 7/8/2016 state Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: ❑ Property Address ® Xiaoxin Yu Owner owner's Name information is required for every North Andover page. City/Town D. System Information Description: Number of current residents: MA 01845 7/8/2016 state Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No April 8 2016 Date Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner owner's Name information is required for every North Andover MA 01845 7/8/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2011 gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Yes ® No ❑ 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) MA 01845 State. Zip Code 7/8/2016 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 18 years old, 11/27/1998, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1_6 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal M. feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10' x 5'x 4' Sludge depth: 2" ❑ Yes 0 No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 9 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street ,p Property Address Xiaoxin Yu Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Cityfrown 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 31" 4" 8" 11" 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.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 Date Tide 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 1060 Turnpike Street Property Address Xiaoxin Yu Owner owner's Name information is required or very North Andover MA 01845 7/8/2016 fe 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: Date of last pumping: gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3113 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 1_* Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner's Name North Andover MA 01845 7/8/2016 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 . 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 full of roots. No liquid present. Broken pipe fitting from pump line. 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.): Unable to remove riser cover over pump & alarm floats, dug inlet cover cannot see pump & floats. Liquid level in pump tank ok. Alarm has both audible & visual. * 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts u1n. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin ,Yu Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ . leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 57' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner's Name North Andover Cityfrown D. System Information (cont.) MA 01845 7/8/2016 State Zip Code Date of Inspection 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1060 Turnpike Street Property Address Xiaoxin Yu Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 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 ❑ drawing attached separately G �v,re cvcv� D-1 U&-Vn zio V5 k t 'q t5ins • 3113 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 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 1060 Turnpike Street Property Address Xiaoxin Yu owners Name North Andover MA 01845 7/8/2016 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/11/1993 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Tide 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 16 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 1060 Turnpike Street Property Address Xiaoxin Yu Owner's Name North Andover City/Town MA 01845 7/8/2016 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 • 3113 Title 5 Official Inspection Fond: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 6/20/2016 11:58:49 AM by Karen Hanlon Status Page 1 j Town of North Andover YTD Cons 13240188 a Active Tax Map # 210-107.C-0008-0000.0 METE METE . Parcel Id 18295 Date Reading Code 1060 TURNPIKE STREET Posted Date Variance 4/21/2016 JACKIE CHEN aActual 9 5/25/2016 1060 TURNPIKE STREET 1/21/2016 659 aActual NORTH ANDOVER, MA 01845 2/19/2016 24% Class 101 Single Family 649 Property Type 1 Residential Zoning2 1 Residential -28% Zoning3 1 Residential Size Total 2.41 Acres 11 8/14/2015 -41% FY 2016 630 a Actual 19 UB Mailing Index -14% 1/22/2015 611 Name/Address Type Loan Number Active/Inact. From Until JACKIE CHEN Owner a Actual 12 1060 TURNPIKE STREET 20% 7/23/2014 577 NORTH ANDOVER, MA 01845 10 8/13/2014 -3% NGUYEN, DAVID Previous Customer Inactive 10/8/2004 10 1060 TURNPIKE STREET 29% 1/23/2014 557 NORTH ANDOVER, MA 8 2/14/2014 1 % 01845 549 aActual 8 ROMERO & MARIBEL GARCIA Previous Customer Inactive 11/15/2010 541 1060 TURNPIKE STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13660.0 - 1060 TURNPIKE STREET Last Billing Date 5/11/2016 1090338 01 Cycle 01 Active UB Services Maint. Account No. 1090338 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 34.20 /1 UB -Meter Maintenance Account No. 1090338 Serial No Status Location Brand Type Size YTD Cons 13240188 a Active 00 METE METE w Water 1 1 362 Date Reading Code Consumption Posted Date Variance 4/21/2016 668 aActual 9 5/25/2016 -9% 1/21/2016 659 aActual 10 2/19/2016 24% 10/21/2015 649 aActual 8 11/20/2015 -28% 7/22/2015 641 aActual 11 8/14/2015 -41% 4/23/2015 630 a Actual 19 5/19/2015 -14% 1/22/2015 611 aActual 22 2/20/2015 85% 10/23/2014 589 a Actual 12 11/14/2014 20% 7/23/2014 577 a Actual 10 8/13/2014 -3% 4/22/2014 567 a Actual 10 5/15/2014 29% 1/23/2014 557 a Actual 8 2/14/2014 1 % 10/23/2013 549 aActual 8 11/18/2013 -2% 7/22/2013 541 a Actual 8 8/15/2013 3% 4/22/2013 533 a Actual 8 5/20/2013 11% 1/18/2013 525 aActual 7 2/13/2013 -22% 10/19/2012 518 aActual 9 11/9/2012 12% 7/20/2012 509 a Actual 8 8/14/2012 14% 4/20/2012 501 a Actual 7 5/9/2012 -12% 1/20/2012 494 a Actual 8 2/13/2012 -21% 10/20/2011 486 aActual 10 11/14/2011 25% 7/21/2011, 476 aActual 8 8/15/2011 26% 4/21/2011 468 a Actual 6 5/16/2011 3% 1/25/2011 462 aActual 5 2/11/2011 -100% BOARD pF'Hl EA �H %—j Sc) i 1,� 1 m 6 TI E S., I hN62T^ ELEVA l 0 N S. 21999 GG = ZZo.1 Z S,r,M• N ZZ, 3' Z�;-S' 11J S,T' = 2 ►�, `ZI pe -,.M.4. 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