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Miscellaneous - 114 ACADEMY ROAD 4/30/2018
114 ACADEMY ROAD J210/096.0-0035-0000.0 11� I I s I i I i t i t&O RTN �6q�G OL O M F- �1 7,4 T/D SSAC HOSE PUBLIC HEALTH DEPARTMENT Community Development Division CYF9(TI(FICAr1-(F OF CO�V1(1'-IANC As of: ,dune 26, 2007 q-his is to cert that the individualsubsurface disposarsystem receiveda SAT'ISEWTORTINSTEMOYof the: Septic Tankand Outlet Tee RepCacement Onry constructed 6y: Todd Bateson At: 114 Academy Wpad 94ap 096.0 - Parcer35 North Andover, X4 01845 9fiie Issuance of this certificate shaCr not 6e construed as a guarantee that the system will function satisfactoriCy. J mere E. Grant fu61icWealth Inspector 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Cf NORTH 7y J Town of North Andover HEALTH DEPARTMENT s�CH CHECK#: DATE: /7 LP 7 LOCATION: H/O NAME: a r CONTRACTOR NAME: P -il Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ Septic Disposal Works Construction(DWC) $ .� ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ 2471 White-Applicant Yellow-Health Pink-Treasurer i I NUMBER _ ��- THE COMMONWEALTH OF MASSACHUSETTS FEE /-7 `'"s------- of .....11�/•_ /�. J • l•' .,;r/..................... . This is to Certify that ---....... . 3�-��5 C- NAME ............................................................... 'ADDRESS --------.--- ------ - IS C HEREBY GRANTED A LICENSE -•' } ! "` / For ._ ------•-�..-•-------�'�����._._�------.lT!1!--------------- .._...-•-•-••------ -• ....... .......................... 1... f� ------ ....... .. . 2i .. �i i"....... Lir,_ .................... ......••---.----•------ --•-•. ... •---••-•---- -•--•- This license is granted in conformity with the Statutes and ordinances relating..thereto, and expires............ i .....................•--- ------•-_•._unless sooner sus ended or revoked. -- u . ---- E 7 e t� --•-•...... -- --- ---•----•-••--•-•-•-•••---•-•--••--.............................. ---�--••• . ............................_._...------•-•••------- ......................._..-_...------•-•-•-----•••--- FORM 489 ........................... H&W HOBBS&WARREN rrn I I „t T h AYA Application for Septic Disposal System _ o TODAY'S DATE 1.Construction Permit - TOWN OF , MA 01845 $ 250.00—Full Repair NORTH ANDOVER $125.00 -Component ,sSACHu541 Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Re air or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component cursor-do not use the return A. Facility Information key. n6 Address or Lot# mn City/Town /V._ –.� ✓t/� �1 2.-*TYPE OF S PTIC SYSTEM*: ❑ Pump ravity(choose one) ***If pump system,attach copy of electrical permit to application*** ❑ Conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed(D-Box Present)S.A.S. 2. Owner Information Name Address(if different from above) Alf Ciry/Tovm State Zip Code Telephone Number 3. Installer Information _ —l cK•�J �i9 ! r?S d„aiiJ _ ^�C�^=-�, r '/P$a N �.�y 7 - _11t'-t'`- Name Name of Company Address City/Town StateZip Code t Telephone 'umber(cell Phone#if possible please) a. Desiciner Information ,r Name Name of Company Address Cityrrown ,C` State' Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page t of 2 a r 04 Application for Septic Disposal System o 'Construction DATE Permit - TOWN OF $ 250.00—Full Repair ORTH ANDOVER, MA 01845 $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issuedA5 this Board of Health. N Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: .For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes_ No 3. Pump System? If so,Attach copy o(Electrical Permit Yes_ No 4. Foundation As-Built?(new construction ronly): Yes_ No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes_ No I SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Fn er) Relative to the application of .+ q 14- (Installer's name) And dated zl ngtna ate Dated � .� �.5.�. ca '7 o ay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all pen-nits and Board of Health approved plans p1jor to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. 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 S50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally,this is the first�W) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK (or e-mail to: healthdept@townofnorthandover com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work(other than.ample excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done 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 to operate in the Town of North Andover, significant fines to all persons involved are also possible 5. 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 HeaAb staff or consultant. d. Installation of tank,D-Box,pipes,stone, vent,pump chamber, retaining wall and other components. 6. 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. f Undersigned Licensed Septic Installer: �-z � `� (Today's Date) /0 (Name—Pnn7t (Name—Signed) I e NORTH OL O * * f 4C �J °'►Argo�� (5 ACHU PUBLIC HEALTH DEPARTMENT fommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: MAP: LOT: INSTALLER: ,� sa✓✓ y DESIGNER: PLAN DATE:' �— BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: eW-7-X DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer El not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access po 1600 Osgood Street,North An over,Moss th 01845 Phone 979 688.9540 Fax 978.688.8476 Web www.townofnorthandover.com NORT►I q 6 O Z. e 044 cnew cww¢.``1. ��SSAGHUS PUBLIC HEALTH DEPARTMENT Community Development Division ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Watertightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base ❑ Inlet tee (if pumped or>0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) I Comments: 2 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com V&ORTft Of,s�aQ agti0 LO ' lA L C. eb~ � O cx.i iwwnc. b TED PUBLIC HEALTH DEPARTMENT (ommunity Development Division SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to 6 in into C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/concrete/timber/block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber Infiltrator Quick 4 ❑ Number of chambers per row 9 ElNumber of rows (trenches) 3 ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside ❑ Alarm signal located inside Comments: 3 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 978.688.8416 Web www.townofnorthandover.com NORTFr 6' OO FO- A � suwi.KpGwc.`1• 9 rap ��SSACHUS PUBLIC HEALTH DEPARTMENT fommunity Development Division SYSTEM ELEVATIONS INVERT IN FIELD PLAN INVERT ELEV. Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 INV Lateral 1 TOP Lateral 2 INV Lateral 2 TOP Lateral 3 INV Lateral 3 TOP Lateral 4 INV Lateral 4 TOP 4 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofoorthandover.rom t%ORT1j 1 ,.O tt�eb 6• �O .�►? 46',x- " ! OL `O f� 1y- �yy T ` T � 10, LANA Ot a � �44TED 9SSACHUS�� PUBLIC HEALTH DEPARTMENT Community Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 10' ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib.to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot.Area ❑ Reservoirs 400 400 ❑ Drains(wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains(Other)Foundation 10(5) 20(10) ❑ Drywells 20 25 1 Suction line 222(2) z 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws 5 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Septic System Information 114-116 ACADEMY ROAD Printed On: Tuesday,June 12,2007 System ID: BHS-2002-1858 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity. Number. p tY� Design Flow Provided: Minutes per inch: Width: Width: Total Flow. Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry. No No Hau/inWPumping Listing Quantity Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons Routine Septic Tank STEWARTS SEPTIC 11/15/2004 1000 Routine Septic Tank ROOLER MAN GLSD 07/07/2005 600 Routine Septic Tank Bateson Ent GLSD 11/24/2005 1000 Inspections: 1 Inspected: Expires: Inspector: Status: 06/07/2007 Neil J. Bateson Conditionally Passes Comments: Received T-5 Report 6/12/07;Outlet tee in spetic tank needs to be replacced and leak fixed in 4"PVC in house. 1 { i GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 i i .i� . Cf NORiM 1ti FO • • p • : Town of North Andover _ '•;,:o : HEALTH DEPARTMENT ,SSACH�stt CHECK#: C Os" DATE: // ©7 LOCATION: H/O NAME: � �;a�rr L ,ecy�yLLlo .. 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 $ a Title 5 Report a ❑ Other. (Indicate) $ 2462 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer { r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENT AIRS DEPARTMENT OF ENVIRONMENTAL PROT T IR U ��� TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address:_114 Academy Road_ North Andover_ JUN 1 2 2007 Owner's Name: William Barrett Homes _ Owner's Address:_P.O.Box 278 TOWN OF NORTH ANDOVER _North Andover,MA 01845_ HEALTH DEPARTMENT Date of Inspection._6/7/2007_ Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,MA 01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ' Inspector's Signature: Date: _6/7/2007_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_114 Academy Road_ —North Andover_ Owner:_William Barrett Homes_ Date of Inspection:_6f7/2007_ 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: X One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.Outlet tee in septic tank needs replaced and leak fixed in 4"PVC in house. N The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_114 Academy Road_ _North Andover_ Owner: William Barrett Homes_ Date of Inspection:_6/7/2007_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance— "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_114 Academy Road_ _North Andover_ Owner:_William Barrett Homes_ Date of Inspection: 6/7/2007— D. System Failure Criteria applicable to all systems: You must indicate`yes"or`no"to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'/z day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No Any portion of the SAS,cesspool or privy is below high ground water elevation. —No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design How of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—MTA)or a mapped Zone R 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. i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_114 Academy Road_ _North Andover_ Owner:_William Barrett Homes_ Date of Inspection: 6n/2007_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? No Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes_ ` Were as built plans of the system obtained and examined? Yes _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,located on site? Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _Yes_ J Existing information. _Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_114 Academy Road_ _North Andover_ Owner:_William Barrett Homes_ Date of Inspection: 6/7/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_N/A Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203 N/A Number of current residents:_0 Does residence have a garbage grinder(yes or no):_No Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use:(yes or no):_No Water meter reading: Yes_ Sump pump(yes or no): Yes_ Last date of occupancy:,House vacant for one year_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Unknown_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1000_gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping: _Inspect baffle&tee TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information_19 years old,8/30/1988, as built plan_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 i, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_114 Academy Road_ _North Andover_ Owner:_William Barrett Homes_ Date of Inspection: 6!1/2007 BUII.DING SEWER_X_ (locate on site plan) Depth below grade: " _30 _ Materials of construction: _X_cast iron _X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast iron thru wall,4"PVC&3"PVC in house.PVC leaking by cast iron._ SEPTIC TANK: X Depth below grade: 20"_ Material of construction: X concrete,metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_7'x 5'x 4' Sludge depth:—2 _ Distance from top of sludge to bottom of outlet tee or baffle:_N/A_ Scum thickness:_1" Distance from top of scum to top of outlet tee or baffle: N/A ff. _ N/A=outlet tee partially corroded o Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc Outlet baffle ok.Outlet tee partially corroded off. Depth of liquid at outlet invert.No evidence of septic tank leaking. Outlet cover has riser 12"deep._ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): v _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 114 Academy Road, North Andover Owner: William Barrett Homes Date of Inspection: 6/7/2007 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J, tenon Bateson Enterprises,Inc. ............ .... . . ...... ... ..... .... 'rowN OF NORTH DOVER SYSTEM PUMPI () R�( pKl, UA l'F. �� J� SYSTEM OWNER& ADDRESS SYSTEM LOCATION DATE 4F PUMPtNQ:_ //1'�_ __—..,.-OI.IANTlTY PUMPED: L LSSPWL: NO YES Snpcic Tank: NU YES N^ f URE OF SERVICE: RUU'f'INk EM RU�NC'Y OBSERVATIONS: GOOD CONDITION PULL To covER F:DC 0 7 2004 HEAVY 0"-ASE BAFFLES IN PIACI. ROOTS _ LSACHPIELD RUNBACK - _� OVER sX(%BSSIVE SOLIDS,___ FLOODED �, r, ; LNT SOLID CARRYOVER_ OTKER EXPLAIN system Pwttpcd by C' ....z�... �-'UMMENTJ. �'UN 1'�:N I'J fKANSF'EKRfiU I�t/ . .._....... Danz 6 Of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSti'1ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART C SYSTEM INFORMATION Propert+ .address: Date of Inspection: RESIDENTIAL FLOW CONDITIONS tuber of bedrooms (design). Number of bedrooms(actual) ,J DESIG\ floe' based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms): 'lumber of current residents: 3 Does residence have a garbage grinder (yes oro Is laundn on a separate sewage system (yes or�g ?__ (if yes separate inspection required) Laundn system inspected Yes r no): _ Seasonal use (yes o noo9:. a!er meter re;dings. if available (last 2 years usage (gpd)): r-jlro k�f •p(fL�i}r�� S'_.r^o pump kf>o11* : mast dale of occupancy C ( 7'/ cfv)" C0)11�1ERCIADWDUSTRIAL )e of establishment: Des!gr. '1(++ (based on 3)0 CMR 15.203) gpd D:sis o'-design flow seats/persons/sgh,etc.): Grease reap present (yes or no): _ ++aste holdln� tank present (yes or no) _ `•0''. �aC!!3r +yaste discharged to the Title 5 system (yes or no) . meter read.ngs, ifayailable: OF occupancy/use OTHER (describe): GENERAL INFORMATION Pumping Records .^:fnr?r.ation. _- ar pumped as pan of the inspection (yes oro: .:!-me pumped gallons How was quantity pumped determined^ Reason for umping l l'f'E OF SYSTEM Sept;c tank, distribution box, soil absorption system — Singie cesspool Ci+r-llo++ cesspool _ Pr„ — Shred s stem (yes or no) (if yes, anach previous inspection records, if ani') !.^.no attve:`A ternative technology Anach a copy of the current operation and maintenance co^tr3ct (to �. r-um sv stem owner) i ght tank Artach a copy of the DEP approval __ Otner (describe): D!; atle of all components. date installed (if knn++nI and source of information r.e se"age odors detected when arriving at the site (yes or67c): — I'� 6 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR •I PART C SYSTEM INFORMATION (continued) Property Address: f f /hc'.got.r�X. 0�,ner: Date of Inspection; BUILDING SEWER (locate on site plan) Depth beloµ grade \?a!er:a!s of consn-action. _cast iron _40 PVC_other (explain): Distance from private water supply well or suction line: Comj'n:^:s (on condition ofjotnts, venting, evidence of lead,age, etc.) SEPTIC TA:ti'K: locate on site plan) �i Death Belo" grade `lateral of construction, :�ncrete _metal _fiberglass _polyethylene _other(e.xplain) :tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no) — (ankh a copy of ') Me^:s:ons /2, - - -- S u02e C;rD:!': � Drt_r.ce ^om top of slu�Re to bosom of outlet tee or baffle: 2 �� 5 m t`, ci;ness: S D,s'ar'l— from top of scum to top of outlet tee or baffle: D.s'.a^ce from bonom of scum to bonom oC outlet tee or baffle 12 e j:mensions determined comments(on pumping recommendations, inlet and outlet tee or baffle condition. srruct.tra, !nttent�, i;q,:;d ;e,,,; n outlet invert. evidence of leakage. etc ) GRE-\SE TR.AP: _(locate on site plan) D.ptr. .,elo,-+ grade _ Mater al of construction: —concre!e —metal _fiberglass _polyethylene — other car lain 1 Di.mensions �1-m th:ckncss ),stance fTom top of scum to top of outlet tee or baffle: j:stance from bonom of scum to bonorn of outlet tee or baffle: Dat: of las! pumping. -1m,ments (on pumping recommendations, inlet and outlet tee or baffle condition, structural inie_nt\. ;:,ui- !,N., c!a:ed :o outlet inven, evidence of leakage, etc.): 7 I Paoe 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLU>\TARY ASSESS NIEN"rS SUBS LRFACE SEWAGE DISrOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION (continued) Property Address: AG Date of inspection: _ Z—aS TIGHT or HOLDING TANK:/L�(tank must be pumped at time of inspeciion)(locaie on site pla r) Depth below °rade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explam) Dimensions - — Ca'ac)r eallons Design FloA gallons/day ^,]arm present (yes or no). Alarm level. Alarm in working order(yes or no): _ Date of last pumpini: Comments (condition of alarm and float switches, etc ) DISTRIBUTION BOX: /,� (if present must be opened)(locate on site plan) Dc�.i'. oi"Iiquil le\el above outlet invert: C) Comments (note if bos is level and distribution to outlets equal, any evidence of solids camover. 3n\ evidence of leakage into or out of bos,etc ): PL QIP CH A%l BER / (locate on site plan) P,:n-:ps :n \+ori:ing order (ves or no): _ Alarms in .orking order (yes or no) _ Comments i note condition of pump chamber, condition of pumps and appurtenances, etc J � I Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F-O RVI PART C SYSTEM INFORMATION (continued) Property Address: Date of Inspection: SOIL ABSORPTION, SYSTEM (SAS): _ (locate on site plan, excavation not required) If SAS not located explain why:. Ts pe leachtnL' p :s. number: _ leachina chambers, number: leaching galleries, number: _ leaching trenches, number, length: _ leachina fields, number, dimensions: 1 _ o\,erOo�� cesspool, number: _ _ tnnova,ive,alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition o-1 \e�'e;ation. etc ) - �D CESSPOOLS/ (cesspool must be pumped as pan of inspecticn)(locate on site plans Dep:n - top of liquid to inletirien: Dc;t- o'-solids layer Di—..ens ons of cesspool �tatcrals of const-r ction: iod!.ztion of zroundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of veaetatton, etc t PRI\'1"'Aq (locate on site plan) N?aierials of construction. Dimensions De^th of sol ds Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition o e�etat or. et; 9 - Page 10 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESS�lE�"] SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR:�1 PART C SYSTEM INFORMATION (continued) ProperiN Address: ytlo Owner: W�i`f �:'� Date of Inspection; Z_OJ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the se Aage disposal system including ties to at least two permanent reference landrnar�s or benchmarks Locate all wells within 100 feet. Locate where public water supply enters the build,n2 Paee l I of I I OFFICIAL INSPECTION F ORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con.tinued) Propert` ,Address: y l y� H s h y Date of Inspection: SIT" EXANI Slo' Su,,,-ace Mater c e -a a ow wells Est mated depth to ground water_ _ feet Pl/ sease indicate (check) all methods used to determine the high ground water elevation y Obtained brom system design plans on record - If checked, date of design plan reviewed. __�ZObserved site (abuning property/observation holy within 150 feet of SAS) 6- Checked with local Board of Health-explain: Checked with local excavators, installers- (anach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 SEPTIC SYSTEM SERVICING REPORT Date:,_ _`1 C>o Homeowne r:` t c�c1 �-d, Pumper Street Address: Phone Phone Nature of Service: Routine Emergency ' Observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) Description of Work: Comments: 4 I i i Pezcif TAS K 3 h � 1 I yEDGE i iG/5 r I D, BOX i � I f � 7 l I PLAN' SHOIIVIN S SUBSURF4, :~' SF1-1AGE DISPOSAL SYSTEiM BATESON p RpR LOCATION ' -'P'-//yY A Cq D4c/y y ROA I] AROt1dII R0. NORT11 A&PO'/ER N/,I, ANDOVER. MA et0 OW N F f, = /',7R, P40L PATE ' AUG, 30, /9d2 Nc)j 7 scn/� i I TOWN OF SYSTEM PUMPING MECO i/?.. ;/ - 4�' - DATE: Lf SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example:left frost of house) P4 DATE OF PUMPING: QUANTITY PUMPED: 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 LEACF FIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAES) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.E_.S.D -/ Lowell Waste i I TOWN OF SYSTEM PUMPING RECORD # -� DATE: / SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) 1e'-Lm +Yd � DATE OF PUMPING: QUANTITY PUMPED : 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(EXPLAIlN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D —, Lowell Waste COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I' DEPARTMENT OF ENVIRONMENTAL PROTECTIO\ TITLE S OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Propertt Address: lI '�C r?/�/}c?j_ 71 }i A0 Os+ner's Name: 7' F1��� h'/-'r,(j. -- Oµner's Address: ti y4 i�C. �'), � � 4 2006 '�Date of Inspection: �t -2 _vs pW� Fhtt . Tt�1°�MDOV R Name of Inspector: (please print) Ed w,9"O.&I Gc Compam• Name: )tailing Address: o2�7c� Telephone Number: CERTIFICATION STATEMENT that I have personally inspected the sewage disposal system at this address and that the repo .;c is rrue. accurate and complete as of the time of the inspection. The inspection was performed based information n m ^2 and experience in the proper function and maintenance of on site sewage disposal systems I am a DEF aapro,,ed system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000). The system _zPasses Conditionally Passes — Needs Funher Evaluation by the Loci .Appro\in .Au;horu Fails Inspector's Signature: 2_ CCGG Date: 0 inspector shall submit a copy of this inspection report to the Approving Author,( (Board o: DEP) within 30 days of completing this inspection. if the system is a shared system or has a design !lo\, of iu.�`;�, od or Preater the inspector and the system owner shall submit the report to the appropriate regional or ic: f c ori2in3l should be sent to the system owner and copies sent to the buyer, if applicable. and .he otr. �;arn,• �r.t. e; ane Comments - ALTHOUGH THIS REPORT MAY BE DEEMED RELIABLE OR GUARANTIES ARE, EXPRESSED OR IiMPLIED. This report only describes conditions at the time of inspection and under the conditions of use .1t !hit ;,Tc. This inspection does not address ho�N the system pili perform in the futu conditions of use. re undrr the i nir ur C:iic'cr !nspect:on Form page I Page 2 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.ni PART A CERTIFICATION (continued) Property Address: IJP _y Q Ary 1) V tER. . Date of Inspection: —Z—0 ti Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D .A. System Passes: LISI have not found any information which indicates that any of the failure criteria de :5.30; or in ;10 CMR I5.304 exist Any failure criteria not evaluated are indicated belo„ cribed in :IU C�'.R Comments: S. St stem ConditionallN 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. ill pas; =•ns• er .-es. no or not determined (Y,\,ND) in the for the following statements. If"not deierm!neC p;ccie The septic tank is metal and over 20 years old' or the septic tank (whether metai or not) is structur.:l.\ unsound. exhibits substantial infiltration or exfiltration or tan}; failure is imminent. System will pass inspect on , :\a :ark is replaced with a complying septic tank as approved b� the Board of Health �� 'A metal septic tank ill pass inspection if it is structurally sound, not leaking and if a Certificate of ComDi;2nct. -Ijicaure that the tank is less than 20 years old is available XD explain Observation of sewage backup or break out or high static water level in the distribution boy du, to broke. ooPructed pipe(s) or due to a broken, sealed or uneven distribution box. System "'ill pass inspection it t\% :tui cc'o a! of Board of Health) _ broken pipe(s) are replaced obstruction is removed — distribution box is leveled or replaced ND e.yplain The s.stem required pumping more than 4 times a year due to broken or obstructed pipits, Th, s\;;,., ss inspection if(with approval of the Board of Health): — broken pipe(s) are replaced obstruction is removed of 1 1 t OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESS:'v1E TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART A CERTIFICATION (continued) ProperrvAddress: ! /C40ice,s/ A;D,. Owner: -a Dale of inspection: 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 ;i tier s) ;em ':::I:.n_ to protect public health, safety or the environment. I. S�stc•m Ns ill pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b) that the system is not functioning in a manner which will protect public health, safety and the en\ironnient. Cesspool or privy is %k ithin 50 feet of a surface water _ Cesspool or pray is wilhin 50 feet of a bordering vegetated wetland or a salt marsh '_. S\Stenl will fail unless the Board of Health (and Public Water Supplier, if ana) determines,that lh� system is functioning in a manner that protects the public health, safety and environmeni: _ Tne system has a septic tank and soil absorption system (SAS) and the SAS is --thin 100 fee� o: sur:ace %ka(er supply or tributary to a surface water supply. The system has a septic tan, and SAS and the SAS is within a Zone I of a public eater scoo'. e s'vsien) has a septic tank and SAS and the SAS is �N ithin 50 feet of a pri�are ,a;er ;u^ni\ fhe ;.stent has a septic tank and SAS and the SAS is less than 100 feet but 50 fc:': o. ate �a e sripok \kell'' Method used to determine distance 'This s%stem passes it the Nvell water anal.sis, performed at a DEP centfied laboraton. :or D:::tc:2 and \olulile organic compounds Indicates that the Nkell is fret from pollution iron that i'.:?a r. r; presence of ammonia nitrogen and nirrate nirrogen is equal to or less than 5 ppm, pro\i,3,,. tha: n.., :he7 failure criteria are irigeered. A copy of the analysis must be anached to this form M I 3. Other: l °a2e0ofll OFFICIAL INSPECTION FORM , NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORN1 PART C SYSTEM INFORMATION PropirtN Address: e O++nee. FoR%�5s �.!�>~-cAeA?e2 Date of Inspection: —L o RESIDENTIAL �`- FLOW CONDITIONS ,uTb:r of bedrooms (design): Nurnber of bedrooms (actual): .j DESIGN now based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms): Number of current residents: 3 Does residence have a garbage grinder(yes or 63IS laun'n on a separate sewage system (yes orQ._— [if yes separate inspection required[ Laundn- system inspected yes r no): — .easonal use: (ves o no): _ as r meter reudine s. it available (last _ years usa^_e (spd)): Cis? j,_,Mp Pump to)o : Last date of occupancy: C C'i7�1 t.' ivy COM)lERCIAL/IN'DUSTRIAL TN- of establishment: Des (based on 310 CMR 15.300: gpd i - Bas!s ofaes gn Ilo�A 0ea(sipersons'sgfi,eic ) Grease rrso present (yes or no): _ -s^:- ++ ! aste holding tank present (yes or no)- _ '3r\ ++aste discharged io the Title 5 system (yes or no) mc;er read!nas. if available. '-3s: 'Z.c of occupancy(use OTHER (describe): Pumping Records GENERAL INFORMATION :. . .fn ratio _ :'._m Pumped as pan of the inspection (yes or(T) -`._,me pumped gallons -- How was quantin pumped determined" ..-ason for ; •-mpine --- T)'PE CF SVSTE�1 /Sr-�uc tarok. distribution box, soil absorption system �!r':•�ie cesspool U+c'llo+ cesspool _ Sneed s.\stem (yes or no) (if yes, arch previous inspection records. if any) !.^.nowt;+•e Alternative technology Anach a copy of the current operation and ma ntenance,, conr•, , - .. M s\Stem owner) c -- _ Twh! tin.� _ Arch a copy of the DEP approval Oi.ner (describey _.e a12e of ail comnonen!s. date installed (if knr`++nt and source of information - - 30 - 055 ='c se•.+age ouors detected when arriving at the site (yes oro. — - - r i Paee S of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-N-1 PART C SYSTEM INFO RIMATION-(continuedi ProperiN Address: .%/'f A0, Date of Inspection: Z�as i I TIGHT or HOLDING TANK/Z/'i (tank must be pumped at time of inspection)(locate on site plant Depth below °rade: Material of construction: _concrete —metal _fiberglass _polvethylene _other(e plain) Dimensions ---- Capacin Sallons Design Flock gallons/dav Alarm present (yes or no). Alarm level. Alarm in working order(yes or no): - Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: j/ (if present must be opened)(locate on site plan) of 110u ' le\el above outlet inven Comments (note '(box is level and distribution to outlets equal, any evidence of solids camover. 3nv evidence o' leakage_ into or out of boa, etc.) Pl. Vf' CHAa1BEft: �(locate on site plant P_mps :n \�min3 order ( es or no): _ A!ar-ms in. %orking order (yes or no)' _ Comments mote condition of pump chamber, condition of pumps and appunenances. etc t Page 9 of I I i i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMEN*TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFOR-m PART C SYSTEM INFORMATION (continued) Properts Address: %f_4/- %c:;.0ctaKs! K1,0 _ 0Aner: 6//<'IQC T L5 1—,-9 c r) Date of Inspection: e?.S" SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required) If SAS not located explain why:. T)pe leach!nL p!;s. number _ leaching chambers, number: _ leaching galleries, number leaching rrenches, number, length: leaching fields. number, dimensions: 1 _ overnow cesspool, number. _ J _ !nnovative,altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of etc) C) CESSPOOLS/' (cesspool must be pumped as pan of inspecuon)(locatc on site plan coni'!gurauon. top of liquid to inlet inven. Dc:n- of solids layer. D!.T_eni ons of cesspool �1a cr; is o;construction: of uoundwater innow (yes or no): _ C_Jmmenis (note condition of soil, signs of hydraulic failure, level of ponding. condition of ece;:t,on ei PRI`"YIL (locate on site plan) `•'atenals of construction. D;M- ns!ons D°atc of solids Com—mews Inose condition of soil, signs of hydraulic failure, level of ponding, condition of Pane I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR Ivq PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SIT EX.AN1 Slo Su—.ace wafer ce, lap al ow wells Estimated depth to around water feet Please indicate (check) all methods used to determine the high ground water elevation: y Obtained Erom system design plans on record • If checked, date of design plan reviewed: _ZObserved site (abusing properry/observation hot- within 150 feet of SAS) C✓Checked with local Board of Health-explain: T�Checked with local excavators, installers-(attach documentation) ,accessed USGS database-explain: You must describe how you established the high ground water elevation: _ I1 TOWN OF kNDOVER SEPTIC SYSTEM SERVICING REPORT Date: �`1�D1� Homeowner:_ 1A�G�n �� Pumper �a� ter ��`�� Address: Phone to Phone Nature of S-a_rvice: Routine Emergency Observation;3: Good Condition Full to Cover Baffles in Place I Leachfield Runback Excessive Solids i — 8 Heavy Grease � I Roots Other (Explain) I i Descript:Lon of Work Comments: it of Na��TH �ti DOVEI�, M4, A.�PL WgTE`{ S��r'L7 Q Tewt-! CJ SS SC�Tlc Sys—IEAA J, std SPP, v ' AJPr OUPJ6 Au1-hoKrry PC�Sn1 DSS, G.�C! �1��v DATA .. �I�QPPRpVEp D _ Co,Jp(SD�JS ��45oNS D 6,71 ScP7'(c SY STEM ►i SU LLAT►OAJ Ex4U4T(oJJ )NSP6:6 T IOAJ 9/ -rC i�SS �] F41l._ (ti5P�r1o�J P(PE F-[7,()A-\ t ►vcJ i c� T/J L1 Pry 55 `tel R)L ��T D�S,�P�'KUvEf� D,arC I�E/J�ti'S• FML APPROVAL DACE ��- � APP►�ov�G ��i Hopi�/ t ' COMMONWEALTH OF MA.SSACHUS ETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i, DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address e�I /ic;quEY11 rJ G - RF_��'��� OKper's Name: T fl«X� �F� ��N 13 2005 Owner's Address: f i rrre /�rdlJ C'G��% ✓ /yiff, NORTH ANDOVER Date of Inspection: Z — v5� �_- TORE OF DEPARTMENT dame of Inspector: (please print) Ephy/�C'c� S;�GC.LSffi Company name: Mailing AddressoX Telephone Number: CERTIFICATION STATEMENT I -en;n that I have personally inspected the sewage disposal system at this address and that the information repo-,d ^c!o, is true. accurate and complete as of the time of the inspection. The inspection was performed based on mv c---:ne and experience to 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 —Z Passes Conditionally Passes Needs Funher Evaluation 'Dy the Local .Appro\in,,, A uthont\ Fails - y Inspector's Signature: C , — Date: fn s,,stem inspector shall submit a copy of this inspection report to the Approving Authority (Board o! eezir: or DE P) within 30 days of completing this inspection. If the system is a shared system or has a design flogs of 1-1 O ^e or greater the inspector and the system owner shall submit the report to the appropriate regional office of the The or ietnal should be sent to the system owner and copies sent to the buyer, if applicable. and the �c;tts ane Comments ALTHOUGH THIS REPORT MAY BE DEEMED BELT'BLE , OR GUARANTIES ARE EXPRESSED OR IMPLIED. ""This report only describes conditions at the time of inspection and under the conditions oruse at that This inspection does not address hogs the system will perform in the future under the s::nte or ciff�rc:t: conditions of use. lnspecuon Form page I Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSINIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART A CERTIFICATION (continued) Property Address: tiro, A1VV.2veFl Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all,of Section D , System Passes: I/I have not found any nformation which indicates that any of the failure criteria described in ;10 C v^,R 303 or, n 310 CMR 15.304 exist Anv failure criteria not evaluated are indicated 'oelo\� Comments: B. Ss stem Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaued The system, upon completion of the replacement or repair, as approved by the Board of Health. will pass ns• e .es no o; not deterrnined (Y,N,ND) in the _ for the following statements. If"not deterrn:nrc' ple7,s. The septic tank. is metal and over 20 years old` or the septic.tank (whether metal or not) is s;ru-tur..'.. ; unsound exhibits substantial infiltration or exfilt-ration or tank failure is imminent. System will pass inspect on m- : s.-r. :an}; is replaced with a complyin-g septic tanR as approved by the Board of Health s metal septic tankill pass inspection if it is srructurally sound, not leaking and i(a Cenificate of Comm anc: ,n' catir:2 that the tank is less than 20 years old is available ND explain Observation of sewage backup or break out or high static water level in the distribution box due ;o broken o- obssructed pipe(s) or due to a broken, senled or uneven distribution box. System will pass inspection if t\%.ic ro a! of Board of Health) broken pipe(s) are replaced _ obstruction is removed distribution box is leveled or replaced 'D explain Thr system required pumping more than 4 times a year due to broken or obstructed pipets). The s m piss inspection if(with approval of the Board of Health) broken pipe(s) are replaced obstruction is removed D Pao 0! jI. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART A CERTIFICATION (continued) Propertt Address: Oµner. 0llF-Sl y/• r_rl� it Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to deter-mine f t',,e :adtn_ to protect public health, safety or the envirorvment. 1. S\stem N+ill pass unless Board of Health determines in accordance with 310 CN1R 15.303(1 )(b) that the system is not functioning in a manner which will protect public health, safe(. and the enN ironment: Cesspool or prs) is \,ithin 50 feet of a surface water Cesspool or pn\� is within 50 feet of a bordering vegetated wetland or a sah marsh '-. S\stem-will fail unless the Board of Health (and Public Water Supplier, if an)) 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 fez; o'a s_rface eater supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public ate, sup !\ T^e system has a septic tank and SAS and the SAS is within 50 feet of a priva!e \\ate. su^^I\ _ fhe system has a septic tank and SAS and the SAS is less than 100 feet but ^nate \,ate. sunol\ \yell•• Method used to determine distance 'Th!s s\sem passes if the well water anal\sis, performed at a DEP ceniriied laborato-\. :o- ;L)! (sr ;t ;a and \oldtiie organic compounds indicates that the \\ell is free from polLt on from that i?c:lu\ an .n presence of ammonia nirrogen and nitrate nitrogen is equal to or less than 5 ppm pro\iced tl;a; no :t.e !allure criteria are triggered. A copy of the analysis must be anached to this form 3 Other: Pa-Re4orll OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propem Address: 1,/`f Date of Inspection: et.— D. System Failure Criteria applicable to all systems: You must indicate -yes'' or''no" to each of the following for all inspections: Yes ''!C Backup of sewage into facility or system component due to overloaded or clo2�ied SAS or cep ssoo! _ Com. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloa ,e or clogged SAS or cesspool _�. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cess000l _ Liquid depth in cesspool is less than 6" below invert or available volume is less than day ilo\� Required pumping more than 4 times in the last year NOT due to clogged or obstructed p pefs� �umoer of times pumped . Ani portion of the SAS, cesspool or privy is below high ground water elevation Ani portion of cesspool or privy is within 100 feet of a surface water supply or tributar\ to a sun-ace water suppiy. Ani ponion of a cesspool or privy is within a Zone 1 ora public well. Ani portion of a cesspool or privy is within 50 feet ora.pri-vate water supply well. Ani portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a pn ate �k ater supply well with no acceptable water quality analysis. IThis system passes if the F+ell' water anal%sis. performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the Hell is free from pollution from that facility and the presence of arnmoni.t nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided.that no other failure cntrriu are triggered. A cope of the analysis must be attached to this forma 1'.s",,o) The s.s stem fails. I have determined that one or more of the above failure cntenc e\:s. described to 310 Ch1R 1i 303. therefore the system fails. The system ow,tr shou! , contact the Boari o, Heahn to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must scree a facility with a design floNs of 10.000 ,pd io 145.000 gPd. You must indicate either "yes" or"no" to each of the following: T'^- following criteria apply to large systems in addition to the criteria above) es no the ss stem is within 400 feet of a surface drinking water supple the s�stem is within 200 feet of a tributary to a surface drinking water supply _ :he s\stem is located in a nirrogen sensitive area (Interim Wellhead Protection area - Ia, o' Zone 11 of a public water supply well — If%ora have answered ''yes'' to any question in Section E the system is considered a significant threat, or ans��frre Section D above the large system has failed. The owner or operator of any large system considered s:2.-.ucant threw under Section E or failed under Section D shall upgrade the system in accordance +ith 3 i0 C !R :! The system owner should contact the appropriate regional office of the.Depanment 4 ' II Page 01 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESS:N1EN'TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /1/67! q.-4aVE��rhA� Date of Inspection: neck if the followine have been done. You must indicate "Yes" or "no" as to each of the followine: Pumping information was provided by the owner: occupant;or Board of Health ere any of the system components pumped out to the previous rwo weeks Has the system received normal flows to the previous rwo week period Have large volumes of water been introduced to the system recently or as pan of this inspection Were a's built plans of the system obtained and examined? (If they were not available note as v _ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out ` \Vere all system components, excluding the SAS, located on site Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for G^e 02,:ie5 or tees. material of construction, dimensions, depth of liquid, depth of sludge and depth o! scum W as the facilir\ o\k iter (and occupants if different from owner) provided \\ith !nto7n2c .C)1i �r !ne _ece of subsurface se��aee disposal s\stems '' i 1': e size and location of the Soil Absorption System (SAS) on the site has been deternnwd oa,rc o- I Existing information. For example, a plan at the Board of Health. �/— Determined in the field (ifan\ of the failure criteria related to Part C is at issue appro�:mauoe is _n cceptable) I3 10 C:v1R 15.3021(3)(b)) 5