HomeMy WebLinkAboutMiscellaneous - 110 LACONIA CIRCLE 4/30/2018 110 LACONIA CIRCLE
_210/105.D-0158-0000.0
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NORTH 6906
ti a
Town of North Andover
HEALTH DEPARTMENT
S�CMUSt
CHECK#: DATE:
LOCATION: Tj
H/O NAME:
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 $
❑ TrashlSolid 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 $
Title 5 Report $1�
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink- Treasurer
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments d� 5
t �
110 LACONIA CIRCLE
Property Address 4 '
CHRISTOPHER MURPHY
Owner 119A � �
Owner's Name � ,�
information is NORTH ANDOVER MA 01845 12/19/14 b
required for every
page. City/Town State Zip Code Date of Inspectio o
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
filling out forms
on the computer, 0,� 015
use only the tab 1. Inspector: JAN
key to move your
cursor-do nota .. " ;3t° ' •'.
JAMES H CURRIER II
use the return
key. Name of Inspector
J'S SEPTIC & DRAIN
Company Name
131 FOREST ST
Company Address
MIDDLETON MA 01949
City/Town State Zip Code
978-774-6685 S12327
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
❑ Needs Further Evaluation by the Local Approving Authority
4.s
12/19/14
Inspector's 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.
t5ins•3/13
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
GSM , 110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. Cityrrown 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:
SYSTEM WORKING PROPERLY
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 an r 2
p and 0 years old or the septic tank(whether meta,seta, 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
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is VE
OR MA 01845 12/19/14
required for every NORTH ANDI
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.):
I
❑ 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
p ( P )
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. City/Town 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 %day flow
(Sins•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
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
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 Oe 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 determir;e 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—I WPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
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?
® El information
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): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 GPD
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
I
Number of current residents: 4
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 ears usage 208 GPD
9 ( Y 9 (gPd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: CURRENT
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-3/13 Title 5 Official 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
110 LACONIA CIRCLE
GSM SVBy`v '
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. Cityfrown 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: LPD 9/11/12 _
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? TRUCK GAUGE
MAINTENANCE, INSPECTION
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)
❑ 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
M 110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
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:
SYSTEM PLAN DATED 8/14/85. NEW TANK AND D -BOX DATED 6/30/00
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
� 36" -4011
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 4
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
PLUMBING IN GOOD CONDITION, NO EVIDENCE OF LEAKAGE.
Septic Tank(locate on site plan):
Depth below grade: 30% 34% RISER 6" -8"
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: 10'6"x 68"- 1500 GALLON
Sludge depth: 3„ -411
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
w u Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 LACON[A CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. CityfTown 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
2311-24"
Scum thickness 0-1"
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
14"
How were dimensions determined? 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.):
TANK WAS PUMPED AS PART OF INSPECTION. INLET AND OUTLET TEES IN PLACE. LIQUID
LEVEL CORRECT.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
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 rHl
g t o 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•3/13 Title 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
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
BOX LEVEL AND WORKING PROPERLY, NO EVIDENCE OF SOLIDS CARRYOVER, LIQUID
LEVEL CORRECT. BOX IS 38" BELOW GRADE. RISER 12" BELOW GRADE.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
N - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. City/Town 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) 44'
❑ 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.):
SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL.
i
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 El Yes E:1 No
t5ins•3/13 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
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
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,
i
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of �u; y, —ridition 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
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. CitylTown 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. 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: 108"
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: 8/14/85
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
TEST PIT DATA SHOWS NO WATER OBSERVED AT 108" BELOW GRADE.
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
r Commonwealth of Massachusetts
u - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 LACONIA CIRCLE
Property Address
CHRISTOPHER MURPHY
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 12/19/14
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Dage 17 of 17
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Summary Record Card generated on 12/15/2014 2:30:41 PM by Maureen McAuley Page 1
Town of North Andover
Tax Map # 210-105.D-0158-0000.0
Parcel Id 17119
110 LACONIA CIRCLE
CHRISTOPHER MURPHY
110 LACONIA CIRCLE
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 3.28 Acres
FY 2015
_UB Mailing Index
Name/Address Type Loan Number Active/Inact, From Until
CHRISTOPHER MURPHY Owner
110 LACONIA CIRCLE
NORTH ANDOVER,MA 01845
GOOD,JOHN Previous Customer Inactive 4/2/2007
110 LACONIA CIRCLE
N.ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17553.0-110 LACONIA CIRCLE Last Billing Date 10/3/2014
3170223 03 Cycle 03 Active
UB Services Maint,
Account No.3170223
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 813.77 /1
UB Meter Maintenance
Account No. 3170223
Serial No Status Location Brand Type Size YTD Cons
33605657 a Active ERT HH b Badger w Water 0.63 0.63 1700
Date Reading Code Consumption Posted Date Variance
9/11/2014 2556 aActual 153 10/15/2014 1029/4)
6/11/2014 2403 aActual 75 7/16/2014 / 203%
3/12/2014 2328 aActual 25 4/11/2014 -39%
12/10/2013 2303 aActual 40 1/17/2014 -70%
9/11/2013 2263 a Actual 136 10/15/2013 369%
6/12/2013 2127 aActual 29 7/24/2013 13%
3/1312013
3/13/2013 2098 a Actual 26 4/22/2013 14%
12/11/2012 2072 aActual 29 1/9/2013 �_y -74%
9/14/2012 2043 a Actual 120 10/15/2012 9
6/11/2012 1923 a Actual 41 7/16/2012 60%
3/12/2012 1882 a Actual 25 4/14/2012 -5%
12/14/2011 1857 aActual 27 1/17/2012 -50%
9/14/2011 1830 a Actual 58 10/13/2011 60%
6/8/2011 1772 a Actual 34 7/20/2011 -40%
3/8/2011 1738 a Actual 55 4/13/2011 12%
12/9/2010 1683 a Actual 48 1/12/2011 -63%
9/13/2010 1635 a Actual 147 10/15/2010 67%
6/7/2010 1488 aActual 80 7/15/2010 1%
3/10/2010 1408 a Actual 80 4/14/2010 30%
12/10/2009 1328 a Actual 62 1/12/2010 -36%
9/10/2009 1266 a Actual 99 10/15/2009 64%
j 6/9/2009 1167 a Actual 57 7/20/2009 23%
3/13/2009 1110 a Actual 49 4/29/2009 -28%
12/10/2008 1061 aActual 67 1/20/2009 3%
9/9/2008 994 a Actual 68 10/10/2008 -13%
6/5/2008 926 a Actual 70 7/16/2008 83%
i
4 CIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
f SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
� I
operty Address: 110 Laconia Circle, North Andover
`�Owner's Name: Good
Date of Inspection: 5/27/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100'. Locate where public water supply enters the building.
HOUSE
B
A.
s�oc.
APP: SEWER
WATER::
1500 Gallon
Septic Tank
FRONT
YARD
0
Box'
SAS
SEPTIC TANK TIES: A to Inlet (1) 1115" B to Inlet 3918"
A to Outlet (0) 2118" B to Outlet 40'4"
D-BOX TIES: A to Box 3714" B to Box 4814"
NOTE: The system is in the front yard. The top of the d-box was about 12"deep following
the installation of precast concrete risers.
Commonwealth of Massachusetts
City%Town of I RECEIVED
System Pumping Record
Form 4 JUN 1 2 2006
T ' ' Oi P';)RTH�I��C�VER
DEP has provided this form for use by local Boards of Health. T e stemlumprn #tec d must
be submitted to the local Board of Health or other approving aut
A. Facility Information
.Important:
When filling out 1. SySt�m LOCA
forms the.
computer,
r,use T—
only the tab key Address .
to move your ®
cursor-do not
use thereturn City/Town Stat Zip Code
key.
2._ System Owner:
Name
i Address(if different from location)
City/Town State Zip Code
Telephone Number
.e. Pumping Record
1. Date of Pumping Date 2. QuantityPumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑wank Tight.Tank
❑ Other(describe)`
4. Effluent Tee Filterresent? '
p ❑ YesIf yes, was it cleaned? ❑ Yes:❑ No
5. Condition of System:
6: System u p d By.
Name Vehicle License.Number
Company
7. Locat' ,where contents were disposed:
Sig tune f baUler Date
h.ttp://www.mass.govidep/water/.Ipptovals/t5forrns.htm#inspect
t5form4.doc•06103
System Pumping Record•Page 1 of 1
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Town of rth ver q
Health Department Date:
Location:
(Indicate Address,if Res' ential,or Name of Business)
Check#:
Type of Permit or License: (Circle) 4
➢ Animal ` $
i
➢ Dumpster $
➢ Food Service-Type. $
➢ Funeral Directors $
➢ Massage Establishment $
➢ Massage Practice $
➢ Offal(Septic)Hauler $
➢ Recreational Camp $
➢ SEPTIC PERMITS:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC)$
❑ Septic Disposal Works Installers(DWI) $
➢ Sun tanning $
➢ Swimming Pool $
➢ Tobacco $
➢ TrashlSolid Waste Hauler $
➢ Well Construction $
➢ OTHER:(Indicate)
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0 f � ' t
PETER F. REILLY
136 ANDOVER STREET
ANDOVER, MA 01810
(978) 375-3750
TITLE V
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A- CERTIFICATION
Property Address: 110 Laconia Circle, North Andover, MA 01845
Name of Owner: John M. and Jocelyn K. Good
Address of Owner: same RECEIVED
Name of Inspector: Peter F. Reilly
Company Name: same JUN - 9 2006
Mailing Address: 136 Andover Street, Andover, MA 01810
Telephone Number: (978) 375-3750 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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-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
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: May 27, 2006
er F. Reily
The system inspector shall submit a copy of this 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 shall submit the
report to the 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 a the time of inspection and under 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 (See attached Disclaimer).
i
i
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
I
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C, D, or E /ALWAYS complete all of Section D
✓ I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
The system met the Pass Criteria of Title V.
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,
will pass.
i
Answer yes,no,or not determined(Y,N,ND). Describe basis of determination in all instances. If"not determined",
explain why not)
N The septic tank is metal, and over 20 years old*or the septic tank (whether metal or not) is 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. *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:
N Observation of a sewage backup or breakout or high static water level 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
I
I
�I
{
t
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A- CERTIFICATION (continued)
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH
Conditions existwhich require further evaluation by the Board of Health in orderto determine if the system
is failing to protect the public health, safety and 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:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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:
N/A The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to
a surface water supply or tributary to a surface water supply.
N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well.
N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a
private water supply well.**Method used to determine distance N/A
This system passes if the water well water analysis, performed at a certified DEP 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. A copy of the analysis must be attached to this form.
3. Other
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A- CERTIFICATION (continued)
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
D. System Failure Criteria applicable to all systems: j
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N/A Liquid depth in cesspool less than 6"below invert or available volume<'/day flow.
No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: once
No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply
s well with no acceptable water quality analysis.(This system passes if the well water analysis,performed
at a DEP laboratory,for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the
analysis must be attached to this form).
N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310
CMR 15.303,therefore the system fails.The property owner should contact the Board of Health should be
contacted to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You Must indicate either"Yes"or"No"to each of the following:
(The following criteria apply to a large system in addition to the criteria above)
N/A The design flow of system is 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
N/A The system is within 400 feet of a surface drinking water supply
N/A The system is within 200 feet of a tributary to a surface drinking water supply
N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such 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.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
Check if the following have been done. You must indicate either "Yes" or "No" as to each of the
following:
Yes No
Yes Pumping information was provided by the owner, occupant, or Board of Health.
I
No Were any of the system components pumped out in the previous two weeks ?
Yes Has the system received normal flow in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes Were as built plans of the system obtained and examined ? (If they were available note as N/A)
Yes Was the facility or dwelling was inspected for signs of sewage backup ?
Yes Was the site was inspected for signs of breakout?
Yes Were all system components, excluding the SAS, located on the site ?
Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum?
Yes Was the facility owner(and occupants of if different from the owner)provided information on the
proper maintenance of subsurface sewerage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes No
Yes Existing information. For example, a plan at the Board of Health.
N/A Determined in the field if any of the failure criteria related to Part C is at issue(approximation of
distance is unacceptable) [15.302(3)(b)].
i
� I
I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms(design): 5
Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203
(for example: 110 gpd x#of bedrooms: 550 gallons
Number of Current residents: 3
Does the residence have a garbage grinder(yes or no): no
Is the laundry on a separate sewerage system(yes or no): no (if yes,separate inspection required)
Laundry system inspected (yes or no): N/A
Seasonal use(yes or no): no
Water meter readings, if available(last 2 years usage[gpd]): about 150 gpd
Sump Pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of Establishment: N/A
Design Flow gpd(based on 15.203): N/A
Basis of Design Flow(seats/persons/sq.ft., etc): N/A
Grease trap present(yes or no): N/A
Industrial waste holding tank present(yes or no): N/A
Non-sanitary waste discharged to the
Title 5 system (yes or no): N/A
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
OTHER: (Describe) N/A
GENERAL INFORMATION
PUMPING RECORDS
Source of Information: owner(about once each year)
Was system pumped as part of inspection(yes or no): no
if yes,volume pumped(gallons): N/A
How was quantity pumped determined? N/A
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
NO 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 the system owner)
Tight Tank Attach a copy of the DEP Approval
Other(describe):
Approximate age of all components, date installed (if known)and source of information: original system installed
in 1986. Replacement septic tank&d-box in 2000. -
Were sewerage odors detected when arriving at the site(yes of no): no
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
III BUILDING SEWER: (locate on site plan)
Depth below grade: about 36"-40"
Materials of construction: cast iron 40 PVC ✓other(explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound at foundation. j
I
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: about 6"-8" (to top of riser covers) about 30"-34" to top of tank
Material of construction: ✓ concrete metal Fiberglass Polyethylene other(explain)
If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A(Yes/No)
I
Dimensions: Rectangular- 1,500 gallons (per plan)
Sludge depth: <1"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: <1"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How dimensions were determined: observation
I
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
Tank was watertight and appeared to be functioning properly. PVC tees in place. Tank was replaced in August
2000. Tank was pumped at the request of the client following the inspection.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other(explain)
Dimensions: N/A
Scum thickness: N/A
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
Date of Last Pumping: N/A
i
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
N/A
i
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
j TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade: N/A
material of construction: concrete metal Fiberglass Polyethylene other (explain)
Dimensions: N/A
Capacity: N/A gallons
Design Flow: N/A gallons per day
Alarm Present (yes or no): N/A
Alarm level: N/A
Alarm in working order (yes or no): N/A
Date of last pumping: N/A
Comments: (condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ locate on site Ian
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into
or out of box, recommendation for repairs, etc.)
D-box was level. Two lines leading to SAS were accepting effluent evenly. No solids carryover evident.
The box cover was originally about 38" below the surface. Pre-cast risers were installed to a new cover
height of about 12" below the surface. The d-box was replaced at the same time as the tank in August
2000.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order (Yes or no) N/A
Alarms in working order (yes or no) N/A
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
I
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required)
If SAS not located, explain why:
Type
✓ leaching pits, number N/A
leaching chambers and number N/A
leaching galleries and number N/A
leaching trenches, number, length 2 -44' long trenches per"As-Built" Plan
leaching fields, number, dimensions N/A
overflow cesspool, number N/A
alternative system (name of technology) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)
Soils in area of SAS appeared normal, no signs of breakout.
CESSPOOLS: N/A (locate on site plan)
Number and configuration N/A
Depth-top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow(cesspool
must be pumped as part of inspection) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
Materials of construction N/A
Dimensions N/A
Depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100'. Locate where public water supply enters the building.
HOUSE
A.: <B
,APP:. BLDG.
VIIATER. SEWER
1500 Gallon.
Septic Tank
FRONT.
YARD
BOX
SAS
SEPTIC TANK TIES: A to Inlet (1) 1115" B to Inlet 3918"
A to Outlet (0) 2118" B to Outlet 40'4"
D-BOX TIES: A to Box 3714" B to Box 4814"
NOTE: The system is in the front yard. The top of the d-box was about 12"deep following
the installation of precast concrete risers.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 110 Laconia Circle, North Andover
Owner's Name: Good
Date of Inspection: 5/27/2006
SITE EXAM
Slope flat in area of system (yard slopes dramatically downward away from system)
Surface water none observed
Check cellar dry
Shallow wells none observed
Estimated Depth to Groundwater>4' (below bottom of SAS - per original design plan)
Please indicate (check) all methods used to determine the high ground water elevation:
Y Obtained from Design Plans on record - if checked, date of design plan reviewed: 1986
Y Observed site (abutting property, observation hole within 150 feet of SAS)
Y Check with Local Board of Health - explain: information on file
Y Check local excavators, installers - (attach documentation)
N Accessed USGS Database - explain: website too complicated
You must describe how you established the high ground water elevation.*
1986 design plan indicates adequate separation. The soils and grade changes in the area indicate no
groundwater in the SAS. However, the precise groundwater elevation cannot be determined for certain
without a soil evaluation test.
*Inspector's Note: Soil Evaluation is the currently recognized method for determining or
establishing the high groundwater elevation. Since I am not a licensed or certified soil
evaluator, I am not qualified to determine or establish the high groundwater elevation
beyond the public information available, such as recent design plans of the site or the
nearby area. My estimation of the high groundwater elevation is based on a due diligence
effort to obtain all available information both on and off the site and my experience as a
certified subsurface disposal system inspector. (see attached Disclaimer)
i
i
DISCLAIMER
i
This passing septic inspection under Massachusetts Title V is in no way a guaranty or
warranty of the inspected septic system. The inspection is a "snapshot in time" and does
not constitute a complete assessment of the quality or potential longevity of the septic
system. The pass/fail criteria are specific and outlined in detail in this report. Under the
limited criteria of a Title V inspection, it is impossible to determine how long any septic
system will last. The inspector made a diligent effort to certify the septic system based on
the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of determining the
high groundwater elevation. This inspector is not a certified soil evaluator and is therefore
not qualified under Title V to determine or establish the high groundwater elevation. The
method used to estimate the high groundwaterfor this inspection was based on the public
records and methods of observation described on the previous page. Groundwater levels
can vary greatly from season to season, year to year and soil evaluation is considered the
most reliable method of groundwater determination under Title V.
i
i
I
i
eter F. Reilly
Inspector
May 27, 2006
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
A ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (�
Property Address: t C) (�L�(�0 ((,` �l r J-C Name of Owner 1`1 b Q r 4- 41t 6R 1•-4
N o 1-h d G v.2 r� VA#,, Address of Owner:
Date of Inspecpon: 3 (: 2 000
Name of b> off:(pin Print) - r-h i 5 _4, Sr i vin e s o v\
1 am a p roved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name-
Company ir 169-An �-j a v1
Mailing Address: I
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, 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-site sewage disposal systems. The system:
_ Passes
XConditionally Passes
— Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date- 3130100
The System Inspector shall submit a copy of this 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
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
The septic tank is leaking and needs repairs (sealing) or replacement. The other components
appear to be working (see the rest of this report).
APR 2
revised 9/2/98 Pagel of 11
i
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH 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
The effluent level in the septic tank was 20 inches below the outlet invert. This indicates that the
tank has is leaking.
The tank will need sealing type repairs or, if severe defects are found, possible replacement.
This will need to be determined by a septic tank repair company,with oversight by the municipal
health department.
The soil absorption system showed no evidence of problems-but little gray water has been
discharged into the system due to the leakage from the tank.
revised 9/2/98 Page3of11
INSPECTION SUMMARY: Check A, B, C, of A
A] SYSTEM PASSES:
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 NO). 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION "�"�� �-v(continued)
+ s
Property Address: 1 j o La, tq I^� (.�, C 1 'C'cLQ- � � 4� .��-11'�-�fi
owner: R V i5R.C4 41A Ve r"-}-
Date of Inspection:
B)SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health). Describe observations:
broken pipets)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipets)are replaced
obstruction is removed
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 WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: C f(� N 0 t"+JA A—V\
Owner:
R u�R r ' 0, r+
Date of Inspection: 3 3 2 0 0
D] SYSTEM FAILS:
You must indicate either"Yes" or"No" as 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 of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_lJ 1 Pr_ 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.
N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
y� !� Any portion of a cesspool or privy is within a Zone I of a public well.
I L 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.
El LARGE SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
/operator
g criteria pply to large systems in addition to the criteria above:
sery a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
af and the environment because one or more of the following conditions exist:
Yes
system is within 400 feet of a surface drinking water supply
system is within 200 feet of a tributary to a surface drinking water supply
system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
ter supply well)
Ther of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST 1 u
ProperY
Address: 0
Owner:Date of of Inspection:
313ul Zuuv
Check if the following have been done:You must indicate either "Yes" or"No" as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health.
Z _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,excluding the Soil Absorption System,have been located on the site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(15.302(3)(b))
_ ✓ The facility owner(and occupants,if different from owner)wee provided with information on the proper
maintenance of Sub-Surface Disposal System.
revised 9/2/98 Page 5of11
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 110 Uo` Cao C�Y-C'u ) nl . 4v,, coo v-e� , Nt e.
Owner: 4(A h I t+
Date of Inspection: 31 0 I O O
FLOW CONDITIONS
RESIDENTIA
Design flow: .p.d./bedroom. — �-
Number of bedrooms(design): S Number of bedrooms(actual):"
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):-1?&
Laundry(separate system) (yes or no):h 0; If yes,separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no): n 0
Water meter readings,if available(last two(2)year usage(gpd): -0 fi fA 11®I
Sump Pump(yes or no):�_O l
Last date of occupancy:ry Y-
COMMERCWL/INDUSTR L•
Type of establishment:
Design flow: d ( Based on 15.203)
Basis of design flo
Grease trap pres t:(yes or no)_
Industrial Was Holding Tank present:(yes or no)_
Non-sanitary waste discharged to the Tide 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: A
System pumped as part of inspection:(yes or no) � 0 In lA_ ( O (7 t7 F"S
i 9. + k
If yes,volume pumped: gallons (OJ I ii ,^
Reason for pumping: 1 l�Q f�N W1 P)V) A C `Fr'12 �L 1 1 Q X It4l d',Q y
0
TY SYSTEM 1
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)
1/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank
Copy of DEP Approval
Other
i
APPROXIMATE AGE of all components,date installed(if known)and source of information: 2•^
Sewage odors detected when arriving at the site:(yes or no)) 0
I
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address- ( DU w vN le, Gi r i—b ' r-4k A+� d u�i nk(A ,
wrr .
Oer: �'
Date of Inspection:
01a0
BUILDING SEWER:
(Locate on site plan) /f
Depth below grader
Material of construction:_cast iron 11�40 PVC_other(explain)
Distance fronp private water supply well or suction line a2fl
Diameter
Commen s:(condition of j ints,venting, evidence of leakae,_etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: 3 1
Material of construction:Yoncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:
Sludge depth---12--.
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: Z" Z_q- �r
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: 2Gt S(il t'�L� --(Vr bA 7"T"b f— ae I$CM pyo �Q Ve 1 S
Comments: UU
(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.)
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction: c trete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of sc to top of outlet tee or baffle:
Distance from bottom f scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation or pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leak ge,etc.)
i
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(coranaed)
Property Address: H Lo,W w Gl Ci r jt ) c: C- \ prw a, V''ew
Owner: }A-, A
Dame of Inspection: 3` I O
TIGHT OR HOLDING TA K: (Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of constru 'oconcrete_metal_Fiberglass_Polyethylene—other(explain)
n.-
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes;_No
Date of pr 'ous pumping:
Comment
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX-_
(locate on site plan)
Depth of liquid level above outlet invert: 37
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.)
PUMP CHAXplan)
(locate on s
Pumps in w (Yes or No)
Alarms in w (Yes or No)Comments:(note condichamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: LA(A i o\ `I y-LtR 6 r+tA .4V'A
Owner: 4o,62 r+
Date of Inspection: 313-o 19-000
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,but 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: T r
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 vegeta'on,etc.)
Z+
iAAI 4f. h 14 j\ Leelr U84
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet inve
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwat
inflow(cessp of must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRR/Y-
(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments:
(note condition of soil, gns of hydraulic failure,level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
-----------------
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ! � o �, � v%�, r, G r�� , N � ���. � �o�,Owner: Q�-
� 6Q r�
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
S�q �-
o r_1
L
® = t b' r �+
ACS
36 5 r�
g 0 = 33
EE = 39,
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) ', l
Property Address: L-0"co N 10- CI r(-Lp KI t;
Owner: "-,A�D)V+ )
Date of Inspection: i O 0
NRCS Report name
Soil Type_
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_Feet
Please indicate all the methods used to determine High Groundwater Elevation:
btained from Design Plans on record
1/ Observation of Site(Abutting property, observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
The ground water determination was made as follows:
1. The original soil logs showed no ground water at a depth of nine feet below the grade, (at
elevation 136 feet). This is well below the elevation of the bottom the soil absorption system
(leaching trenches).
2. Probing was done below the distribution box. No ground water was encountered at 12-14
inches below the box.
3. The home sits on a hill, well above most of the surrounding terrain.
revised 9/2/98 Page 11 of 11
i
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
8/11/00
This is to certify that
the individual subsurface disposal system
constructed O or repaired (X)
Note: Septic tank,distribution box and connecting line ONLY
by
David Currier
at
110 Laconia Circle
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.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
i
Wednesday,April 26,2000 4:19 PM To:Starr,Sandra From:Prof.Thomas E.Phaeln Jr., 729-4372 Page:1 of 5
Name:Prof Thomas E.Phaeln Jr.
Company:Phalen&Allen Ltd.
Voice Number:'729-7117
Fax Number:729-4372
Fax 4 Eugene Drive
Winchester,Mtn 01890
Date: Wednesday, April 26; 2000
Total Pages: 5
Subject: Hubert septic tankTC
____
1 5
_ .a,
I
Name: Starr, Sandra
MAY 2 2 r
Company:
Voice Number: j
Fax Number: 1978688-9542
Note: These are the septic tank repairs contemplated for the Hubert
residence in North Andover and are currently being priced by
contractors.
Wednesday.April 26,2000 4:19 PPA To:Starr,Sandra From:Prof.Thomas E.Phaeln Jr., 729-4372 Page:2 of 5
CRACK REPAIRS ON SEPTIC TANK
OF AN EXISTING SANITARY DISPOSAL SYSTEM
FOR
HUBERT RESIDENCE
110 LACONIA CIRCLE
NORTH ANDOVER MA.01845
BY
p2
C�JO�GdLL�L//� U/L�LILGGF`
�isd�istvwU..A�09890
78>-78s-7947
.$�79�7x9 f87x
APRIL 18, 2000 '
CRACK REPAIRS FOR SEPTIC
� .Tti Of TANK REPAIRS OF AN EXISTI N G
1�G SANITARY DISPOSAL SYSTEM �'aiL9u�L6 �'iL�uL�cv
E SANITARY DISPOSAL SYSTEM
ftik HUBERT RESIDENCE172 4�8 �na
'pFG� �, 110 LACONIA CIRCLE Wm,4eo .fit OMAI
F STEIN c�E. 78;r-7"-71l"7
�SAaIVgI f���0 NORTH ANDOVER MA.01845 7sy, �7x
APRIL 18,2000 SET I
Wednesday,April 26,2000 4:19 PM To:Starr,Sandra From:Prof.Thomas E.Phaeln Jr., 729-4372 Page:3 of 5
I
TANK WALL
2 PART EPDXY t=0,25"
WASH SURFACE WITH ACETONE
ca
3"
0 EXPANDABLE GROUT IN
. SCOURED JOINT
CRACK REPAIR (NTS)
z -
SELF STICK MASTIC
BITUTHANE by W. R.GRACE
CRACK OR JOINT
CRACK REPAIR SCHEDULE
1.REPAIR FROM INSIDE(SEE NOTE 6)
A.SIMPLE CRACK EXPANDABLE GROUT ONLY.
B.SIMPLE TIGHT CRACK BITUTHANE ONLY.
C.MAJOR CRACK EPDXY RESIN ON ACETONE CLEANED SURFACE.
D.MAJOR CRACK BITUTHANE OVER EPDXY.
E.MEMBRANE APPLICATION SEE SHEET 3.
2.OUTSIDE REPAIR
A.EXCAVATE BY HAND. CLEAN AND DRY CRACK LOCUS AND APPLY
1A,B,OR C AS CONDITIONS WARRANT.SEE NOTE 6.
3.FOR AN AREA WITH MULTIPLE JOINTING USE 2D ONLY.
4.ALL AREAS SHALL BE WIRE BRUSHED,WASHED OR CLEANED BY
JET AIR AND HOT AIR DRIED FOR !A ONLY.
5.CONSTRUCTION JOINT REPAIR USE 2B ABOVE.
6.SPRAY CLEAN LOOSE DEBRIS.THEN WIRE BRUSH TO CLEAN CONCRETE SURFACE,
SPRAY CLEAN AGAIN AND FINGER DRY WITH BLOWN AIR FROM LEAF BLOWER.
7.AFTER COMPLETION OF THE WORK THE REPAIR WILL BE TESTED BY THE CONSULTANT
FOR WATER TIGHT INTEGRITY.THE CONTRACTOR WILL NOT BE HELD RESPONSIBLE FOR FAILURE
CRACK REPAIRS FOR SEPTIC
SN OF TANK REPAIRS OF AN EXISTING .6/Ami 60
how�oZ► ( SANITARY DISPOSAL SYSTEM &*-4-1iAW XV,;eev
E SANITARY DISPOSAL SYSTEM
jR C11 HUBERT RESIDENCE F�iee��oe
110 LACONIA CIRCLE " °''��09A90
o�Fsslrol A1.EE NORTH ANDOVER MA.01845 -95 g- :P7¢�.u7--
APRIL 18,2000 SET 2
Wednesday.April 26,2000 4:19 PM To:Starr,Sandra From:Prof.Thomas E.Phaeln Jr-, 729-4372 Page:4 of 5
NOTE: THE MEMBRANE SHALL BE J. P. STEVEN'S E P MEMBRANE WIT
ONLY HEAT WELDED SEAMS. L
�E
W
4..1 L T TOP ANCHOR SYSTEM
j SEE DETAIL D+6
_____ - OUT ET
/ D
TYPICAL CUT LINES HEAT----"7"
EA
WELD EACH CUT 2"WIDE ;�' TYPICAL CORNER
REINFORCING&
HEAT WELDED TO
TYPICAL INSIDE SEPTIC BAGNTS) PRIMARY BAG
E CUT D+6"
x
- -- =
D+6"
+ "
D 6
O _ -
x
TYPICAL CUT LINES HEAT WELD EACH CUT 2"WIDE
SINGLE SHEET BAG DIMENSIONS AND CUTS(NTS)
8.5"SQUARE
8.5"% s..
CUT & \
r
WELD ALL SEAMS ARE HEAT WELDED
TYPICAL CORNER REINFORCING(NTS)
E. P. LINER FOR SEPTIC TANK
SWI OF, REPAIRS OF AN EXISTING ��
SANITARY DISPOSAL SYSTEM
E SANITARY DISPOSAL SYSTEM
At r HUBERT RESIDENCE dna eQreae
9F 110 LACONIA CIRCLEraaleur�d�At 09890
s/�ISTfR� k� NORTH ANDOVER MA.01845 y=8f7.4X,07x
FS NAI. EN ��
APRIL 18,2000 sHEET 3
Wednesday,April 26,2000 4:19 PM To:Starr,Sandra From:Prof.Thomas E.Phaeln Jr.. 729-4372 Page:5 of 5
TANK
WALL
2" HEAT WELDED SEAM
f% x
STAINLESS STEEL CLAMP
4"INLET AND/OR OUTLET TEE f
! M
� r
PREFABRICATED MEMBRANE
SLEEVE OR MADE IN FIELD
MEMBRANE BAG
J. P. STEVENS EP MEMBRANE
DETAIL A OUTLE & INLET TEE
(NTS)
/ FASTENER WITH NEOPRENE
WASHER 12" OC IN SLOTTED
/HOLE WITH METAL WASHER
ALUMINUM OR STAINLESS STEEL
F TERMINATION BAR
TANK TERMINATION AT TOP OF TAN
WALL ;.'• NEOPRENE
WASHER (NTS)
<--E. P. MEMBRANE
E. P. LINER DETAILS FOR SEPTI
N Of, TANK REPAIRS OF AN EXISTING sal,Aioirraa
err( SANITARY DISPOSAL SYSTEM
SANITARY DISPOSAL SYSTEM
•!R y HUBERT RESIDENCE 4�iece�isae
P 110 LACONIA CIRCLEZl*a&u� t o�g90
`ass/Ory/ALAE NORTH ANDOVER MA.01845 Y-x�987 9�.07--
APRIL 18,2000 -EET 4
e NORTN Town Of North Andover
- p Community Development & Services William J. Scott
Director
27 Charles Street
(978) 6889531
North Andover, Massachusetts 01845
ACMU`�t�
Fax 978-688-9542
April 25, 2000
Board of
Appeals Robert Hubert
(978) 688-9541 110 Laconia Circle
North Andover, MA 01845
Building
Department Re: Notice of Conditionally Passing Septic System
(978) 688-9545
Dear Mr. Hubert:
Conservation
Department The North Andover Health Department has received and reviewed the inspection
(978)688-9530
report that resulted from the inspection of your septic system on March 30, 2000.
The DEP approved system inspector has determined that your system was not
Health "...failing to protect or threatening public health and safety or the
Department environment..." as defined in Title 5 of the State Sanitary Code. However, he
(978)688-9540
did determine that "One or more system components ...need to be replaced or
repaired." After review of the inspection report, the Health Department has
Public Health
Nurse determined that you must retain the services of a North Andover licensed septic
(978) 688-9543 system installer to obtain a disposal works construction permit and replace your
leaking septic tank.
Planning
Department In addition, this office finds that your system was designed and constructed to
(978) 688-9535 serve a dwelling of four bedrooms, (maximum of nine rooms), and your
inspection report states that there are five bedrooms in the house. Please be
aware that operating a septic system in excess of the design capacity puts a
severe strain on the system, and may contribute to a system failure. Also, if you
were to desire to construct an addition to the house, the Health Department
would be obliged under law to disapprove the application. Please try to conserve
water whenever possible in order to extend the life of your system. Annual
pumping of the septic tank is also beneficial.
Please have all work performed within 90 days of the receipt of this notice.
Should you have any questions, please call me at 978-688-9540.
Sincerely,
Sandra Starr,R.S., C.H.O.
Health Director
Cc: File
HOFTq Town Of North Andover
Community Development & Services William. Scott
Director
27 Charles Street (978) 688-9531
�� *# North Andover, Massachusetts 01845
SSACHUSE
Fax 978-688-9542
April 25, 2000
Board of
Appeals Robert Hubert
(978) 688-9541 110 Laconia Circle
North Andover, MA 01845
Building
Department Re: Notice of Conditionally Passing Septic System
(978) 688-9545
Dear Mr. Hubert:
Conservation
Department The North Andover Health Department has received and reviewed the inspection
(978) 688-9530 report that resulted from the inspection of your septic system on March 30, 2000.
The DEP approved system inspector has determined that your system was not
Health "...failing to protect or threatening public health and safety or the
Department environment..." as defined in Title 5 of the State Sanitary Code. However, he
(978)688-9540
did determine that "One or more system components ...need to be replaced or
repaired." After review of the inspection report, the Health Department has
Public Health
Nurse determined that you must retain the services of a North Andover licensed septic
(978) 688-9543 system installer to obtain a disposal works construction permit and replace your
leaking septic tank.
Planning In addition this office finds that stem was designed and constructed to
Department your system g
(978) 688-9535 serve a dwelling of four bedrooms, (maximum of nine rooms), and your
inspection report states that there are five bedrooms in the house. Please be
aware that operating a septic system in excess of the design capacity puts a
severe strain on the system, and may contribute to a system failure. Also, if you
were to desire to construct an addition to the house, the Health Department
would be obliged under law to disapprove the application. Please try to conserve
water whenever possible in order to extend the life of your system. Annual
pumping of the septic tank is also beneficial.
Please have all work performed within 90 days of the receipt of this notice.
Should you have any questions, please call me at 978-688-9540.
Sincerely,
Sandra Starr,R.S., C.H.O.
Health Director
Cc: File
�L\ Commonwealth of Massachusetts ---
City/Town of NO. ANDOVER RECEIVED
a W� System Pumping Record JUN - g Zoog
4�M SV 0•'v
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other fo s
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer,use 110 LACONIA CIRCLE
only the tab key Address
to move your NO. ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
CHRIS MURPHY
Name
' Address(if different from location)
City/Town State Zip Code
. Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 15 0s
3. Type of system: ❑ Cesspool(s) U/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ea/No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Benjamin Shute H79 406
Name Vehicle License Number
J's Septic& Drain
Company
7. Location where contents were disposed:
GLSD
5/6/09
re Hauler Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMP NG RECORD RECEIVE®
DATE: _�_ �� SEP 14 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
A (example:left front of house)
� c
Uaco
DATE OF PUMPING: 0 QUANTITY PUMPED : S 0 n GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
I
J
.APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PE'MIT
DATE: 30 -- Cu=NT INSTALLER'S LICENSE
LOCATION: // LeIC091le Clrle 'f I?/G
LICENSED FILER:
i
TELEPHON
SIGNATU 4` _ ET
Z
CHECK ONE:
REPAIR: VVY CONSTRUCTION:
IF NEW CONSTLTCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
575.00 Fee Attached? Yes L/ No
Foundati -Buiit? Yes No
Floor Plans? Yes No
Approval Date:
I
,� I
Hoath Town of North Andover, Massachusetts
?°
t, �•° b,'ti BOARD OF HEALTH Form N0. 3
. „„5DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant
NAME / yt-
Site Location DRESS
r TELEPHONE
Permission is hereby granted to Constructor Repair an Individual S Absorption
Sewage Disposal System as shown on the DApproval
pp A ( 'I
� oval S.S. No
AIRMAN, BOA
HR F HEALTH
Fee
D.W.C. No. �/�
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
(S100j
i
�--e* ko�st
�, ldtacovii-a Cr,
s
DATE OF PUMPING: "L_ 0202 0 9,- QUANTITY PUMPED : , 5 Do GALLONS
i
CESSPOOL: NO J YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIDULD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: L. ' .1 )
i
i
a qry o� Town Of North Andover
Community Development & Services William J. Scott
►- � - -. � p Director
27 Charles Street (978)688-9531
North Andover Massachusetts 0 184 5
9SSACHU`�k�
Fax 978-688-9542
August 11, 2000
David Currier
Board of Currier Septic and Drain
Appeals 107 Forest Street
(978) 688-9541 Middleton, MA 01949
Building Dear Mr. Currier,
Department
(978)688-9545
This correspondence is in regards to the septic tank replacement done at 110 Laconia
Circle,North Andover. This office is concerned about the events that transpired around this
Conservation unusual tank repair. As you may recall,the permit for this property was issued as a tank
Department
(978).688-9530 repair. (see the attached copy of thepermit) This document clearly indicates the intent to
repair, however, upon closer inspection by you,this office was notified that the tank was
severely damaged and must be replaced. At that time it was not known what further action
Health would have to be taken to complete this repair. I full expected to be notified of theintended
Department p p Y p
to ded
(978)688-9540 plans as soon as a solution was determined,just as we had initially approved the previous
decisions. Unfortunately, the next communication received from your office was a request for
Public Health a bottom inspection for the tank hole.
Nurse I responded to the request on Monday, August 7h, to find site alterations that greatly
(978)688-9543 alarmed me. A large area of steep slope had been filled in around the rear of the home to help
bring the heavy equipment to the septic area in the front yard. This was done as an alternative
Planning to causing mutilation of a very extensive landscaped area, with alternating steps and railroad
Department ties. The problem with this alternate work area was its proximity to a wetland. Looking
(978)688-9535 through the foliage and researching the file, it was clear to me that the wetland was most likely
within 100' of the new fill. Due to these findings I notified the Conservation Department to
investigate.
Brian Lagrasse, Acting Conservation Administrator,went to the site and subsequently
informed me that the closest point of work to the wetland was approximately 60'. He
instructed your workers on actions to ensure the safety of the wetlands. I was informed that
hay bales were then placed to keep silt from entering the wetland in case of erosion problems.
There is no question that this project was within the 100' of a wetland and would have
required filing with the Conservation Department. Had the Health Department been
contacted, as the appropriate form of action should have been, this problem could have been
avoided. As the licensed Installer you are responsible to inform this office and any other
relevant departments of any work you are considering in the Town of North Andover. At no
time dider
or f
ou ask mission to fill
y p any area on that site.
Please be advised that by determining your own course of action in this and any
other project, you place your license to operate within North Andover in jeopardy. You are
also opening up the homeowner and yourself to enforcement orders, fines and extensive
remediation requirements. Any subsequent actions of you or your employees that have not
been properly approved by this department will result in a request to appear before the BOH to
1
s
I
discuss suspension or revocation of your license to work as an installer in North Andover. j
In conclusion, Health Department personnel have inspected the septic tank replacement
at 110 Laconia Circle. It is also noted that the distribution box and the line connecting the two
components have been replaced as well due to their deteriorated condition. The Certificate of
Compliance has been issued on this property. A copy of the certificate is enclosed with this
letter for your records and the original will be sent to the owner of 110 Laconia.
If you have any questions concerning this correspondence please contact the Health Department
at 688-9540.
Sincere y,
/Us
Ford, R.S.
Health Inspector
Cc: Sandra Starr,Health Director
Owners, 110 Laconia
N. Andover Conservation Dept.
file
i
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i
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t 4
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� SEWER vu.t J�d-O Z
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INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the property
at &� 4-INCGti.Zg g4Dz relative to the application of C
dated for plans by and dated ° -with
revisions dated `Q
I understand and agree to the following obligations for management of this project:
1. As the installer I am obligated to call.for any and all inspections. If homeowner, contractor,
project manger, or any other person not associated with my company schedules an inspection
and the system is not ready then item two shall be applicable .
2. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without completion
of the items in accordance with Title 5 and the Board of Health Regulations may result in a
$50.00 fine being levied against my company.
a) Bottom of Bed—generally first inspection unless there is a retaining wall which should be done first. Installer
must request the inspection but does not have to be present.
b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from
engineer must be submitted to BOH,after which installer calls for inspection time. Installer must be present
for this inspection. With pump system all electrical work must be ready and able to cause pump to work and
alarm to function.
c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site.
3. As the installer I understand that persons or companies not associated with my company may
not perform the work required by my company to complete the installation of the system
identified in the attached application for installation. I further understand that work by others
unlicensed to install septic systems in North Andover can constitute reasons for denial of the
system, and/or revocation-or suspension of my license in the Town of North Andover plus
significant fines to all persons involved.
4. As the Installer I understand that I must be on site during the performance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff.
d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components.
5. As the installer I understand that I am solely responsible for the installation of the system as per
the approved plans. No instructions by the homeowner, general contractor, or any other persons
shall absolve me of this obligation.
signed Licensed Septic Installer
-'�
Date: G
I t
RECEI O/ED
IL
Commonwealth of Massachusetts
W City/Town of NO. ANDOVER CIS� 4 'tGiZ
System Pumping Record TOWN OF NORTH ANDOVER
9 HEALTH DEPARTMENT
Form 4
GSM v<y`0v
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 1. System Location:
forms on the
computer,use 100 LACONIA CIRCLE
only the tab key Address
to move your NO. ANDOVER MA 01$45
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Vf
Q
JEFF CONTI
Name
I
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 9/11/12 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
JAMES H. CURRIER H79 406
Name Vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
9/11/12
i
Signature of'Hauler rDate
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1