HomeMy WebLinkAboutMiscellaneous - 11 CHERISE CIRCLE 4/30/2018 (2) I 11 CHERISE CIRCLE
210/0610-097-0000.0
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MAP # LOT
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CONSTRUCTION 13 0 L ti
HAS PLAN REVIEW FEE BEEN PAID? CYE5�' NO
PLAN APPROVAL= - DATE 7Lp / APP. By-
DESIGNER: ����� �� � PLAN DATE;_
CONDITIONS k9 6`07--:54 367/' CDFG
WATER SUPPL
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WELL PERMIT DRILLER
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BA ' ERIA I DA I E (IPPRUVED _
BACTERIA I DATE APPROVEll_�_.
COMMENTS
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FORM U APPROVAL: APPROVAL TU ISSUE '
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL: .
ALL PERMITS PAID �� Y____ES NO
WELL CONSTRUCTION APPROVALY S� NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL -" YE NO
OTHER -S NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DA I'E: ' r��/3` ...B
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• + �� NO
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.TYPE OF- CONSTRUCTION•
_ NEW REPAIR' I
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=•NEW CONSTRUCTION: ,`. . CERTIFIED PLOT PLAN REVIEW--' NO
` s ' CONDITIONS OF:.APPROVAL - ,: YES NO
(FROM FORM U)
—ISSUANCE OF DWC PERMIT NO
DWC ';,. •: ,' ,.
PERMIT N0. '. ' INSTALLER:
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BEGIN INSPECTION
_. EXCAVATION .INSPECTION: : NEEDED:
1' SS C
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ASED
-:CONSTRUCTION INSPECTION: NEEDED:
a;�}: , ;' � � . .. ;fit _ � • , t. _ •., . .• ,
AS BUILT PLAN SATISFACTORY: "
APPROVAL TO BACKFILL: DATE: BY
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FINAL . GRADING APPROVAL: DATE �/ G q A—r—BY
FINAL CONSTRUCTION APPROVAL:
DATE: �TIGs BY
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information RECEIVED
filling out forms
on the computer,
use only the tab 1. inspector: MAR 3 2017
key to move your
cursor-do not John DiVincenzo
use the return Name of Inspector TM OF HEALTH DEPARTMENT key.
J and S Development Corp/Stewarts Septic Service
r� Company Name
58 South Kimball St
Company Address
Bradford MA 01835
Cityrrown State Zip Code
978-372-7471 s113386
Telephone Number License Number
3
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that t e
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ e s rt r valuati by the Local Approving Authority
the
tor's Signature Date
system inspector sh it a copy of this inspection report to the Approving Authority(Board
ealth or DEP)withi 0 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.6/16 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1h day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 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
10 11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence ?
es deuce have a garbage grinder. El Yes ® N
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
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.doc•rev.6/16 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Stewart's Septic
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Site guage on the truck
Reason for pumping: To inspect the tank
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
26"
Depth below grade: 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.):
Septic Tank(locate on site plan):
8"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. Cityrrown 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
30"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape measure sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles are good. No leakage and the liquid level is good.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
H w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. Citylfown 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.):
Equal distribution no solids carryover and no leakage
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
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:
❑ 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.):
No hydraulic failure, no ponding and no damp soils.
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 The 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. Cityrrown 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 p blic water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
erl
I
V
1
�t
553`��
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. Cityrrown 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: 7'
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. 7-27-94
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Pulled file
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Water at elevation 129.0, bottom of system at elevation 133.0
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 11 Cherise Circle
Property Address
Kate Gennetti
Owner Owner's Name
information is
required for every North Andover Ma 01845 3-14-17
page. City/Town 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
a "Th 7759
M 9
Town of North Andover
' '••,,,.,'.. HEALTH DEPARTMENT
CNUSE�
CHECK#: 1 DATE: 3 NOn
LOCATION: NQ6 SP
H/O NAME: rnP. n,0k T jj'
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ TrasWSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
xTitle 5 Report $ 50 -
0
50 —
❑ Other:(Indicate) $
Hea ent Initials
White-Applicant Yellow-Health Pink-Treasurer
RECEIVED
Commonwealth'&Massachusetts
Title 5 official Inspection Form JUL 17 2013
Subsurface Sewage Disposal System Form-Not for Voluntary Assessmeg OWN OF NORTH ANDOVER
HEALTH DEPARTMENT
lug11 Cherise Circle
Property Address
Diane Albert
Owner Owners Name
information is
required for every North Andover MA 01845 6-19-2013
page. Cityrrown State Zip Code Date of Inspection
l
Inspection results must be submitted on this form. Inspection forms may not be altered in an
way. Please see completeness checklist at the end of the form. I -I
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not John DiVincenzo
use the return Name of Inspector
key.
J and S Development Corp.dba Stewart's Septic Service, Andover Septic
Q Company Name
58 South Kimball st
Company Address
�+ Bradford Ma 01835
City/Town State Zip Code
978-372-7471 s113386
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. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Nees Fu her aluation by the Local Approving Authority
� 619 �3
Inspe is Signature Date
The ystem inspector shall submit a copy of this inspection report to the Approving Authority(Board
of ealth 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
11 Cherise Circle
Property Address
Diane Albert
Owner Owners Name
information is
required for every North Andover MA 01845 6-19-2013
page. Cityfrown 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
11 Cherise Circle
Property Address
Diane Albert
owner owner's Name
information is. North Andover MA 01845 6-19-2013
required for every CitylTown state Zip Code Date of Inspection
page.
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
t5ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection . Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
11 Cherise Circle
Property Address
Diane Albert
Owner owner's Name
information is North Andover MA 01845 6-19-2013
required for every State Zip Code Date of Inspection
page. City/Town
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) 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 Y2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
11 Cherise Circle
Property Address
Diane Albert
Owner Owners Name
information is
required for every North Andover MA 01845 6-19-2013
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 Tile 5 Official Inspection Forth: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
11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is
required for every North Andover MA 01845 6-19-2013
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 660
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
11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is
required for every North Andover MA 01845 6-19-2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
s
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
Commerciallindustrial Flow Conditions:
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 Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments11 Cherise Circle
Property Address
Diane Albert
Owner Owners Name
information is
required for every North Andover MA 01845 6-19-2013
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Andover Septic
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500 Gal
gallons
How was quantity pumped determined? Site guage on truck
Reason for pumping: Inspect tank
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is
required for every North Andover MA 01845 6-19-2013
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
7-27-1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
20"
Depth below grade: feet
Material of construction-
[9 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.):
Septic Tank(locate on site plan):
4"
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
rh Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is North Andover MA 01845 6-19-2013
required for every North
State Zip Code Date of Inspection
page.
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
.5
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
Tape Measure , Sluge judge
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Both tees in place, No leakage, Liquid level good
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
t5ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is North Andover MA 01845 6-19-2013
required for every State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 rile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f
t
11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is North Andover MA 01845 6-19-2013
required for every State Zip Code Date of Inspection
page. City/Town
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.):
No soilds cant'over, equal dist box, no leakage in box, in good sound condition
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*if pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is North Andover MA 01845 6-19-2013
required for every City/Town State Zip Code Date of Inspection
page.
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length:
2-42'Trenches
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No hyraulic failure, No ponding, No solids carry over, No signs of vegetation.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
t5ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is North Andover MA 01845 6-19-2013
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•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
t
,.•'" 11 Cherise circle
Property Address
Diane Albert
Owner Owner's Name _
information is North Andover
required for every MA June 19,2013
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:
h'J hand-sketch in the area below
❑ drawing attached separately
i
HODS-
I
revised 9/2/98 Page 10 or 11
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 11 Cherise Circle
Property Address
Diane Albert
Owner owner's Name
information is
required for every North Andover MA 01845 6-19-2013
page. Cityrrown 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: 7
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: 7-27-1994
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Pulled Files
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Plans Draw by Christinson &Sergl 7-27-1994 , Water at elevation 129, Bottom of system @ 133 4'
seperation.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
11 Cherise Circle
Property Address
Diane Albert
Owner Owner's Name
information is
required for every North Andover MA 01845 6-19-2013
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
f
COMMONWEALTH OF MASSACHUSETTS
— EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property
Property Address: II r f/ltll'Il[ C%Q0L1t l N• QNDOUVX Name of Owner ftT—T*'R
Addreu of Owner: Ill C t+ft tZ 1 Se C, s(z.C.t-1c- , �•q-fvDdV�(Z
Date of Inspection: 9�Z�/99
Name of Inspector: (Please Print) Benj amin C. Osgood, Jr
I am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000)
Company Name: New England Engineering Sery res Inc.
Mailing Address: 33 Walker Rd. , Snite 23, Nart-h Andover, MA 01845
Telephone Number: 978-686-1768
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-sitesews a disposal systems. The system:
_ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails �1
Inspector's Signature: Date: / Z
719 5
The System Inspector shall submit a copy of is inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
sliall submit.the report to the appropriate regional office of the Department of-Environmental Protection. The original should'be sent Lov"
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
' r
revised 9/2/98 Page I or II
%j* PnNcd on Recycled Val— ,
t •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION.(continued)
Property Address: // Cf/�/�/J� C/�'CGG' IN• NµDpJr�-g—
Owner: p,�iCt'Alj L/fYt, "�
Date of Inspection/0 r/91
INSPECTION SUMMARY: Check A, B, C, Of A
A. • SYSTEM PASSES:
V I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection;or
the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic;tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumpirtg-Tnore than lour-times n yeardue to broken or vtrstnrcted pipe(s). The system Wit Van�
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
r
revised 9/2/98 Page.2orit
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: N14ti1DOUBK
Owner: G rZ= /ye
Date of Inspection: 7/z//9,9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICKYdILL.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVJBONMEH.T:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALT4f AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic 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. Method used to determine distance (approximation not valid).
3) OTHER
) 's
revised 9/2/98 Page 3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: // ClMierS,e C 1XV i-E Al . Wplkle_lle_
Owner: le&WgZY_ CA'er-fie
Date of Inspection:'210 1
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup c4 sewage into iecilityor•"stem component-duego an overloaded or-clagged SASor•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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
—coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is--within 200 feet of-0 tril rtery to a eurfao"ri-k -water supply --- - -
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supply well) '
The owner or operator of any such system shall upgrade the system in accordaPce with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further inforMation.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: j/
Owner: Afl3J le f Ci9Y/�c�
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yeses No
Pumping information was provided by the owner, occupant, or Board of Health.
+� 7 None of the system compooanu.hauabaan puaiped:for-AJeast two xvOaks An&tha rystsm hasAmooaeceiwog weal A 0 w
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with NIA.
I/ _ The facility or dwelling was inspected for signs of sewage back-up.
V _ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
v All system components, excluding the Soil Absorption System; have been located on the site.
_✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was.inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)I
The facility owner(and.occupaaus if differaw from-ommed.wete pramided.with infnrmAtipapn tha pinper maint.na ^f
Subsurface Disposal Systems.
i
s
r 4
revised 9/2/98 e2gesortt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: !! CCy< �f� �i��t i .✓_ .�1�Dlj//F�
Owner: Pi�&3811-r7I C/fDL%XC F'
Date oflnspecdon:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1Y5 g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual):-3
Total DESIGN flow (00
Number of current residents: `f
Garbage grinder(yes or no): 10'
Laundry(separate system) (yes or no):ye5; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):_
Water meter readings,if available(last two year's usage (gpd):
Sump Pump(yes or no): Ato
Last date of occupancy:-9f—V�Iefly
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd 1 Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present:(yes or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available: -
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed{if known)-and source of4M*rmation: 'y 0�72 S
Sewage odors detected when-arriving at the site: lyes or no)
revised 9/2/98 1`2ge6orIt
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.SYSTEM INFORMATION(continued)
Property Address: E C1-e'�V"K-1 "(' ,�"dDl iC
Owner: e qJe lm' -
Date of Inspec6on,*
BUILDING SEWER:
(Locate on site plan)
fl
Depth below grade:
Material of construction:_cast iron Z40PVC_other (explain)
Distance from private water supply well or suction line
Diameter
4 to
Comments: (condition of joints, venting, evidence of Iaakage,-etc.)
P t PE t5 rt�.,) t k
SEPTIC TANK:_
(locate on site plan)
r/
Depth below grader
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is (petal,list age_ ls.age-confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 15-0c) �S
Sludge depth: 4--( " (( _
Distance from top of sludge to bottom of outlet tee or baffle: 3 S
Scum thickness:—4 h
Distance from top of scum to top of outlet tee or baffle: a1 ��
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: M%04SL,1Xf 57GK
Comments:
(recommendation f.or pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structur.ot4ntegrity,
evidence of leakage,etc.) %.9-�e<-
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
e i '
4 f
revised 9/2/98 Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /t C Ht Foe i S k <r G •� N. /�✓J�l.'i�
Date of kupection•
17 2-1 l99
TIGHT OR HOLDING TANK:(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
(locate on site plan)
�+ 0
Depth of liquid level above outlet invert: V
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — —
f7 X /K fir;!D CUitl�/17o/�C NO /fG Dcf lrlCE C'� Ly Com'
C c/V—sz— T/O tir /S Q✓fl L
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
i )
revised 9/2/98 P2RC8OfII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(jcontinued)
Property Address: Il C EfT(2- LSE. e-t 2c E, A-), .4Wj)OVEC/L
Owner: DE( ,i g�pr-K cA r)?-7feL
Date of Inspection: Zrf q
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:_
leaching galleries, number:_
leaching trenches,number,length: yG G Ei9Crf T.�E�tr�rFS
leaching fields,number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
/�. 8a— O` SyST l� GodKS C�c�r� /Vo 0//Y f LJHL"sciftt
CESSPOOLS:
(locate.on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of pwwing,condition of-vegetation, etc.) _
PRIVY: W
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
f )
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART G
SYSTEM INFORMATION(continued)
Property Address: I( C k-K Pb e C l 17-4 4 N, +#J-3 Je4e-
Owner: qce"NJ2H Ceq2q1e-ge-
Date of kupec6on:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i
HOUSE.
I
53.
i
4
revised 9/2/98 Page 10 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 121f&91-1f
Date of knpection:
q12-Vf9
NRCS Report name je,, S� ✓l�Y �G t SS&� ���r"%`� /VS�Ll1j/Sf= l`�a>zr2N I�i9�e-rte
Soil Type_ YVIp�CAut� oi� wrrv�S��rZ
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 7 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
C Obtained from Design Plans on record
Observed.Site (Abutting property, observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
PFS(r-N P'L'H"i r N b i
rc X r S�•�c/ C,72fi--rte,
C. S. �M�oavYry�`N �,Ypic � G(j�1—i7ye
r3k r_e>ui cJfz-f-��G.
`f y
revised 9/2/98 page itorit
No......................... Flea..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN ..........OF....................NQRT..H....ANDOVE.K..................:.......
................................
Appliration for din o Ml o��lt Cion tx roan rrntit
Application is hereby Made for a Permit to Construct ( x ) or Repair ( ) an Individual Sewage Disposal
System at:
CHER.ISE CIRCLE ...................................... ............................................ ...•..._ .........................................
Location-Address or Lot No•
.......... X011...CQ.I`I�];RUCKI.Q�I:..��i�........ .......... 1.?...ROGERS...RD.r..,....I AV RHILL.,...MA..................
Owner Address .
............................................. ......................................... ............................................ ...........................o.................
InstallerAddress
Type of Building Size Lot.....�4.76........Sq. feet
Dwelling— No, of Bedrooms.............6+............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures
Design Flow.............8.2..5....................gallons per person per dayy Total daily flow................6..........................gallons.
. t _ ft r _ n t n
Septic Tank—Liquid'
capacttyl S 0 0„gallons Length 1,0 6„ Width.6......8.... Diameter................ Depth.5•,,.,-6,,,,
x
Disposal Trench—No. _2............... Width.....2............. Total Length....54........... Total leaching area..59!..........sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft,
Z Other Distribution box ( x ) Dosing tank ( )
'-' Percolation Test Results Performed by.....C H.R.I_S T I A N S EN,, & S E R G j-�-„I N(bate.......XAK.........
Test Pit No. per inch Depth of Test Pit.....1.05....... Depth to ground water....�6...............
(Z4 Test Pit No. 2... ..Z...minutes per inch Depth of Test Pit....�b��r..... Depth to ground water.....q...............
P4 .... ...................................................................................................................................................
O Description of Soil......a.-'?A .J3?J?$Q!1�..�...s��ER5s5.Q!L...........................................................................................................
'�' .. S.A7A��.-. �.��....>F I N . !!It..
..................................................................................................................
” 6rMY
9.6........IA�.....................................A...................................................................................................
.....
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'11T1.1, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ................................
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:................................................................................................................
.............................................................................................................................................----...-----------..........................................
Date
PermitNo......................................................... Issued.......................................................
Data
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Talifiratr of Tilnlplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................................................................................................................................................................................................
Installer
at.................................................................................................•.........................------.............................................................--......
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......................... .........................................OF...............................................................I....................., FEs........................
lliopooal Workii 0,10n.5trartion WrMit
Permission is hereby granted................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
...............................................................•-•---...............................-----
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, BOSTON
FORM U - IAT RELEASE FORD
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******************
APPLICANT: ,� cJhJ Phone .37/ �
LOCATION: Assessor' s Mao Number Parcel
Subdivision KA (/Sl Lot(s)
Street C GU C]�'C� St. Numbe_ t
************************Official Use Only************************
RECOMMENDATIO S OF TOWN AGENTS:
Date Approved
Conservation A ministrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved 9
Septic Inspector-Heal-:: Date Rejected
Comments
Public Werks - server/water connections
- dr_vewav permit
Fire Department
Received by Building 1^=_rector Date
1
\y,1a 't1,kWxt i•..ti �`` \�i1 �Ycy'.,'�'t ♦ _"• t pt 1 tia Z t ':\
. \_. t \'t t` xh.. t ti�.S♦.1�y^``,�.y r M a.A� \ 1 9 �`w � 1 \y 5
t y `••C -r r E Y•i v jt r T 1'.kp •- v �\ .t \c c �+^�.. '
i j y�j� 1`�^R, yv� , i .Mv\�•y 1�it� i 1 \ Y:t> 5 r
` - t.{ t-.� -�•,• a �aZ,i 4 t\ \4l'�' Cv!•i l• � � t t 41 ,
�;\ i't :. � � 1 -.ti l ..�: it.�.\ i�tn!'. •`i `` tT ) 41,,`�ti7��' ,i �` ' tii:l � • t�:v.; �.
�. h },► • 't �t. ` - �,t 7 �:t ••�•.'�. •+-,e'1.' ILY+. � • `� �'i.r k T) \y t •�. •fit h.3t t=•
t � �c • �ti ? , t 1i•` •�-. af"!� �D �} 1 '• k( t• t t�!f. � � 5
� ,,- y t � i ' t �r j ♦7'i•'1 �� �'\t,S�'t�� T�� •c1
ti'�t `r it ,.; • �E � � , � i .t, T� �,> � �! '.l 7 71 y t..,7 �•,
' 1 ��' t.' ;��� t� va nz ,1 o;i 1.�LrY � a� r\. e�'•1 f 4 1.ff a. � f `l:
Town of North Andover, Massachusetts Form No.3
NpRTI{
BOARD OF HEALTH
f' •,� p V ' 19 vyl
+,�•�a..,, �'�h DISPOSAL WORKS CONSTRUCTION PERMIT
SSACMUSE
Applicant
NAME ADDRESS TELEPHONE
Site Location S
Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption
: Sewage Disposal System as shown on the Design Approval S.S. No.
C..
U� CHAIRMAN, BOARD OF HEALTH
Fee �%�� ' D.W.C. No.
RECEIVED
'C'\ Commonwealth of Massachusetts
W W City/Town of NORTH ANDOVER JUL 7 2013
' TOWN ERS stem PumpingRecord HEALTHDEPARTMENT
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ! Ch Q r I S C C I
key to move your Address
cursor-do not NORTH ANDOVER Ma
use the return City/Town State Zip Code
key.
2. System Owner:
0-1 bp-r�
Name
ienm
Address(if different from location)
City/Town State Zip Code
Telephone Number
R Prrmnimt Rorrnrrl-.
Town of North Andover, Massachusetts Form No.2
Of NORTH BOARD OF HEALTH
F R 19-f-q
w
s
• •
' •�- DESIGN APPROVAL FOR
ss,C""SE` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant - ,LA t Test No.
Site Location T
Reference Plans and Specs. Z EAE ENGINEER DESIGN
f,.
Permission is granted for an individual soil absorption sewage disposal system to be installed
�3.
in accordance with regulations of Board of Health.
• CHAIRMAN,BOARD OF HEALTH
3•
Fee fin, t Site System Permit No. CoS 7
'y 5F
IV46 )h AIVWve-r 2.6. 4,,
).3b NI4in JC-f. S SEPTIC TANK SERVICE
47 RAILROAD STREET
Iva,-I h A nimwar BRADFORD, MA 01835
14-mal Lot- 1 S/-cam 978-372-7471
MMU of e' -,ber k()
IMTrW REFpKl' FOR 'MWN OF
DATE ADDRESS GA NS
8rlun 9111
)566
763 GU )Y)
i �
1506
1406
1�- 7cla t4l h4er.5
rem i a�
e-
/0/0
f t5 sm rpr3
f�
56
°4 Commonwealth of Massachusetts _
C411 own of NORTH ANDOVER, MASSACHUSETTS
System' Pumping Record
Form 4 ' OCT 12 2006
DEP has provided this form for use by local Boards of Health.+The System Pumpirig Record mu;
be submitted to the local Board of Health or other approving authority-- — ---�
A. Facility Information -
Important:
When filling out 1. System Location: ,
forms on the
computer, use
only the tab key Address
to move your
cursor°do not _.-- —,.
use the return city/Town State Zip Code
key.
2. System Owner:
— --- --.-----.._.___._...__..------_.__._.___.__._.--_._.._._
Name
Address(if different from location)
City own __�_._...- --------- State
Telephone Number
B. Pumping Record
1. Date of Pumping ��--- 2. Quant
it Pumped:
,✓ Q ---._--
Date y p Gallons
3. Type of system: ❑ Cesspool(s) keptic Tank ❑ Tight Tank
❑ -Other(describe):
4. Effluent Tee Filter present? ❑ YesA o If yes, was it cleaned? ❑ Yes ❑ No
r
5. Condition of System:
6. Syst em Pumped By:
�---
ams ----------- -....
Vehicle License Number
Vt,
Company
7. Location where contents were disposed:
l
Date
SI ature of Ha
http://www,maskgov/dep/water/ provals/t5forms.htm#inspect
t5formCdoc°06/03 System Pumping Record •Paget of ,