HomeMy WebLinkAboutMiscellaneous - 114 SPRING HILL ROAD 4/30/2018 (2) 114 lr-fTtfml -
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MORTGAGE INSPECTION PLAN
NORTHERN ASSOCIATES, INC.
342 N.MAIN STREET ANDOVER MA. 01810 TEL-(978) 4744410 FAX:(978) 474-5067
MORTGAGOR: ,JACKS PHILIP AND VICTORIA DEED REF. . 3313/154
LOCATION: 114 SPRING HILL ROAD PLAN REF. 9779
CITY,STATE: ANDOVER ,MA SCALE: 1=60'
DATE: 1/5/99 JOB #: 98/18057
173�s
LOT 16
56,9471SF
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All 1,fq00D
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152.65'
R=60.00'
SPRING HILL ROAD
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DOLBEN
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QM EY 114 Spring.Hill Rd., N.Andover, MA
DESIGN
Sheet Title: 1.:3T
23 California Road Date: fo.
Reading, MA 01867
(781) 942=0146 Sheet No. ! of Pj
O 2002 Nancy Twomey
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TOWN OF
SYSTEM PUMPING RECORD
'�✓7✓��/ RECEIVED
DATE:
. l� NOV - 9 2005
TOWN OF NORTH ANDOVER
HFALTHSYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house) ,
DOI
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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 LEACIHWLD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
4-�
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
Commonwealth of Massachusetts
v ,
Massachusetts
stem Potning Record
System Owner System Location
Date of Pungpint;: lo, � Quahtily Pumped: (�C�gallons
Cesspool: No h+ Yes Septic Tank: No U Yes
System Pumped by: etecoolf 5#&e me4 License#
Contents tlansferrred to : Greater Lawrence 8atiltary District
Date: Inspector:
CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MASS.
9
SCALE:1"= 40' DA TE:5/5/2007
Scott L. Giles R.P.L.S. 67472007
Frank. S. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
18 37
39.57' 19.52'
u � �
�CISgERti�
G 1f°7 LOT#'6
h PLAN #9 779 N.E.R.D.
56,947 S.F.
o4iSr
F� AoR o
cy
42�, 2 STY
881+1-
OFFSETS
8+1OFFSETS SHOWN ARE FOR THE USE
OF THE BUILDING INSPECTOR ONLY
SPRING HILL AND SUCH USE IS FOR THE
ROAD o DETERMINATION OF ZONING
CONFORMITY OR NON-CONFORMITY
I CERTIFY THAT WHEN CONSTRUCTED.
THE OFFSETS
SHOWN COMPLY
WITH THE ZONING
BYLAWS OF 157,60'
NORTH ANDOVER
WHEN BUILT
� VfORTp q
OR LEL
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�SSAC
PUBLIC HEALTH DEPARTMENT
Community Development Division
Date: June 26,2007
Address: 114 Spring Hill Road,North Andover,MA 01845
Re: Application for remodel master bath and expand build porch
To: Sumi Dolben:
Your application for a master bathroom remodel and deck addition at 114 Spring Ifill Road has
been reviewed by the Health Department. The application was denied on, June 26.2007 for the
following reasons.Please note that multiple attempts to contact you and your contractor were
made to discuss this issue, but were unsuccessful:
1. x Missing information
2. x Passing Title 5 inspection of septic system required
3. x Location of structure not acceptable(tank under the deck)
4. ❑ Undersized septic system
To address the problem-(s .
H#1 is checked, please supply:
a. Floor plan of existing and proposed addition—all rooms
b. Certified plot plan showing house, septic system and proposed project in scale
If#2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size
of the system and whether it is operating properly: OR
b. Tie-in to municipal sewer
If#3 is checked:
a. Once a plot plan has been submitted, the location of the septic system in
conjunction with the deck will be established.
If#4 is checked:
a. Provide additional information proving that the existing septic system meets current opacity
requirements. Please consult an engineer to determine the flow capacity of the septic system.
1600 Osgood Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
u s
Sawyer SAS
Cc: Building Department
File
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Town of North Andover o� NORT##1
Office of the Health Department
o
Community Development and Services Division i y
27 Charles Street � _ tir ,"
North Andover,Massachusetts 01845 �qs"'na•**ccy
SACHUS�
Sandra Starr Telephone(978)688-9540
Health Director Fax (978)688-9542
March 31,2003
Mr.and Mrs.Dolbin
114 Spring Hill Road
North Andover,MA 01845
Re: Application for an addition to an existing home
Dear Mr. and Mrs. Dolbin:
Your application for an addition at 114 Spring Hill Road has been reviewed by the Health Department. The
application was denied on March 31,2003 for the following reasons:
1. ✓ Missing information
2. ✓ Passing Title 5 inspection of septic system may be required
3. ✓ Location of structure not acceptable
To address the problem(s):
If#1 is checked, please supply:
a. Floor plan of the existing dwelling including the basement,first floor and second floor. All
rooms must be accurately named;
b. Certified plot plan showing house,septic system and proposed project in scale,including any
associate grading.
If#2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the
system and whether it is operating properly: OR
b. Tie-in to municipal sewer.
If#3 is checked:
a. The proposed the project must meet all current Title 5 Setbacks
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Since ly,
rian .LaGrasse,Health nspector
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
I<& 4- XJ5cx ti%% e.*pa:v
FORM U - LOT RELEASE FORM vwr-t a. 3 s�as�
- a. � -- o 3
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
}G APPLICANT �'ea %e � SV IrPHONE -01,?P
LOCATION: Assessor's Map Number L l A-- PARCEL .12-3�
SUBDIVISION LOT(S
STREET ST. NUMBER 11`d
************************************OFFICIAL USE ONLY***********************************
RECOM NDATIONS OF-TOWN AGENTS:
CONSERVATION ADMINISTRA OR DATE APPROVED 3
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED
9 DATE REJECTED T31 03
! �+S S his
COMMENTS < ,'C! :-r' 117 AAAki,i,,.I
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
1 Revised 9\97 jm
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SETTS
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EXECUTIVE OFFICE OF ENVIRONuFmAL AFF
4IRS.
DEPA tTMEnTTA4F ENVIRONMENTAL.PRO.TECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address•
�
Owner's Name: REf!
-
Owner's Address: sC
JUL 2 3 2007 L
Date of Inspection:
TOWN OF NUR FH ANDOVER
Name of Inspector. (please print) fj kC HEALThi QEPARTMENT
Company Name•
Mailing.Address: 6 - -
Telephone Number.
CERTIFICATION STATEMENT
I cetify 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:punuant WS of Title5,(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's SignatureCk Date: "�7
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 buycr, 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
conditions of.use. how the system will perform in the future under the same or different
Tide 5 Insneninn P. .,, �c�t cnn�n
-
Page 2 of 11:
(� `ICYAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESMEITS
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION F -R,
PART A
CERTIFICATION (continued)
Property Address:IN 5,0024
Owner:
Date of Inspection: — —U
Inspection Summary:.Cbeck A,B,C,D or E./ALWAYS complete allof Section D
A. System Passes:
I have not found any information which indicates that anv 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.
Cowmen
B. System Conditionally Passes:
One o ore system components as described in the"Conditional Pass7scfion need to be replaced'or
repaired.The sys upon completion of the replacement or repair,as,app ved1bythe Board of Health,will.pass.
Answer yes,no or not dete ed(Y,N,ND)in the for the fo owing statements.If"notdetermined"please
explain.
The septic tank is metal and.o 20-years did* o e.septic tank(whether metal or not)is structurally
unsound,exhibits substantial inft}tration exfltrati or tank failure is imminent.System will pass inspection.if the
existing tank is replaced with a complying se is as approved by the Board of Health. =
'A metal septic tank will pass inspection if it i aurally sound,not leaking and if a Certificate of Compliance
indicatincy`that the tank is less than 20 years d is ailable.
ND explain:
Observation of sewage ckup or break out or high s 'c water level in the distribution box due to broken or
obstructed pipe(s)ordue to roken,;scnled or uneven distribut n box.System will pass inspection if(with-
approval of Board of Heal
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replace
ND explain: l
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:
Page3 of l l
.L
` . OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY A.SSESSME 'TS
SUBSIF' CE SEWAO DISPQSAL SYSTEt1� ISPECTIOri FORM
T A
CERTIFICATION(continued)
Property Address:l.L( S n ,
Owner•.
Date of inspection:
C. Further aluation is Required by the Board of Health:
Conditions ist which require further evaluation by the Board of Health m rder to determine if the system
is failing to protect pu 'c health;safety or the-environment.
1. . System will pass unl Board of Health determines is accordanc .with 3.10 CMR 15.303(Ixb)that the
system is not functionin 'n a manner which will protect public enith,;alety and the environment:
Cesspool or privy is with' 0 feet of a surface water
_ Cesspool.or privy:is within S eet of a bordering vege d wetland or a salt marsh
2. System will fail unless the Board of Health(a ublic Water Supplier,if anO determines that the
system is functioning in amanner that protects e p lie health,safety and environment:
The System.'has aseptic tank-,and so- on
surface water.supply or tributary to.a ace abi.so ti.. su pp
(SAS)and the SAS is within_1:00 feet of a. .
_ .The Wstern has aseptic di SAS and the SAS is wi a Zone I of aSPP Yic P ublwater: 1 .
. � .
The system has a septi and SAS and the SAS is within feet of a private water supply well:
The system has a optic tank and SAS and the SAS is less than 1 0 feet but SO feet or more horn a
private.water suppl ell•:...Method.used to determine distance
"This system asses if the well water analysis.performed at a DEP cerci t d laboratory. for coliform
bacteria an olatile organic compounds indicates that the well is free from ollution from that facility and
the prese ce of ammonia nitrogen and nitrate nitrogen is equal to or less than ppm,provided that noother
failur riteria are triggered.A copy of the analysis must be attached to this fo
Other:
a.
Page 4 of 11 ,
OFFTCIAI SPECTION FORM:-NOT FOR VOLUNFARY°ASSESSMENTS
�I7BSURF'ACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
-. PART A
CERTIFICATION(continued)
Property Address: S
.=--L-
3
Owner.
Date of Inspection:
D. System Failure Criteria applicable to all.systems:.
You.''ust 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 clogeed SAS'a cesspool
_ .Discharge'or ponding ofeffluent 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
cesspool invert due to an overloaded or clogged SAS or
Liquid depth in cesspool is less than 6"below invert or available vohune is less than''/-day flow
Required pumping-more than 4 times in the last vear NOTdue 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..fWof a surface wateusupply,oT 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,feetof a private water supply well.
AnyPardo n of a cesspool or privy is less than 100 feet.:but,greawthan 50°feetfrom a.private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed ata DEP certified laboratory, 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 copyof the analysis must be attached to this form.)
(Yes/No)The system sails.I have detertnined,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 la system the syste must serve a facility with a design now of 10,000 gpd to 15,000
&pd.
You must indicate either'y "or"no"to ach of the following:
(The following criteria apply large s ems in addition to the criteria above)
yes no
the system is within 400 t of a surface drinking water supply
the system is wi ' 00 feet o a tributary to a surface drinking water supply
_
the systemis 1 ted in a nitrogen ensitive area(Interim wellhead Protection Area—IWPA)or a mapped
Zone II of a blit water supply we _
If you have answ "yes"to any question in Section E the system is considered a significant threat,or answered
'"Yes"in Section above the large-system has failed.The owner or operator of any large system considered a
significant threa 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.
a. Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMEl\"TS
SUBSUIRFACE SEWAGE DISP,
OSAL,SYS. 'M I�tSPECTIOMFO%M.
CHECKLIST
Property Address: Ll N
l!:�j 14ko
Owner: 4 v C►.�
Date of Inspection:
Check if the following have been done.You mustindicate"Yes"or"no"as to each of the followins: :
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?
ZL Has the system received normal flows in the previous Two week.period 1)
Have large volumes of water been introduced to the system recently oras part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as NIA)
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,po pts,excluding the SAS,located.on site?
o _ Were the septic tank manholes uncovered, opened.and the interior of the tank inspected for the the
he baffles or tees,material of constructiondimensions,stops,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems'
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no N� 6 L �1� ... ..
Existing information.For example, a plan at the Board of Health.
'— –_ Determined in the field(if any of the failure criteria related to Pan C is at issue approximation of distance
is unacceptable)[3 10 CMR 15.302(3)(b)j
5
Page 6 of I l t
z `�' CIAL:INSPECTION'FO tM=IVASSESSMENTS
`FUR VOIrTNTAR '
SUBSURFACE SEWAGMSPUSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address•• t
N o cti ct.
Owner: . ,J
Date of Inspection:
LOW CONDITIONS
RESIDENTIAL
Numlier of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x it of bedrooms):
Number of current residents: 2,
Does residence have a garbage grinder(yes or no):. `'
Is laundry on a separate sewage system(yes [if yes separate inspection rc"iredj;
Laundry system inspected(y or
Seasonal use:(yes or no):/
Water meter readings, if av�ilab}e(last?years usage(gpd)):
Sump pump(yes or no
�.�
Last date of occupancy
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15203): smd
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:`pi%3•►ti
Was system,pumped as part of the ins tion(yq ok n :IV
_
If yes, volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
/ ...e ared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Altemative 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 kno" and source of irif0cmation.
S �,.1
Were sewage odors detected when arriving at the site(yes or no):—AJ
d
Page 7 of I 1
OFFICIAL INSPECTION FORM--NOT FOR:VOLUNTARY ASSE5SMEh"TS
SSF10E SP'GVAGE:DISPOSAL:SYSTEN INSPFCT7ON FORM
:PART C
SYSTEM INFORMATION(continued)
Property Address: S ry h L°
Owner: S
Date of Inspection: '� ;rU
BUILDING SEWER(locate on site plan)
Depth below grader
Materials of construction:,castiron _qo pVC other(ex .lain):
Distance.from private water suiplY well or suction line: /U 04"
Comments(on condition:of joints,venting, evidence of leakage, etc.):
SEPTIC TANK: (locate on site plan) b Lc (e - C'_ev v"'l S
Depth below grade: _t
Material of construcu'ozY: concrete_metal_fiberglass
—other(explain) -_polyethylene
If tank is meta_l. list
age:•_ Is ago confirmed by a Certificate ofCompliance Lv
certificate) es or no):_(attach a copy of
Dimensions:
Sludge depth; u e
Distance'from top of sludge to bottom of outlet tee or baffle .Z
Scum thickness:
Distance from top of scum to-top of outlet tee or ba`'ffle: 7th e$
Distance from bottom of scum to bottom of outlet tee or baffle..
How were dimensions determined:_�^
Comments(on pumping recommendations,filet and outlet tee or baffle condition,structural integrity, liquid levels
as relateo to outlet ert, evidence of leaks ,.etc.):
i ( ..e.L-,� L4 levdcl CJvICc lam_
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete
(explain): metal_fiberglass_polvethylene ocher
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
az related 10 outlet invert,evidence of leakage,etc.):
Page 8 of I l `•�
OFFICIAL INSPECTION FORM- NOT POS VOLUNTARYASSESSMENTS
SItSURFACE`SE``VAGE DISPOSAL:°SYSTENi`INSPECTION FARM .
'PART C
SYSTEM INFORMATION"teontinued)
Property Address:ZP1l' ti 1 vL g t(
Owner. c>. 61 h le v�
Date of Inspection: --�'�
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain).
Dimensions:
Capacity: stallons
Design Flow: pllons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
PS
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover.any evidence'of
ge ou{of box e ): ,.
� 3 a �
fcr
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of I I'
a
OFFICIAL INSPECTION FOR_NOT FOR VOLUNTARY ASSESSME.N�I'g
SIBSURFACE:SEWAGE�DISPOSAL SYSTEii1VSPCTION.FORM
k C .
SYSTEM INFORMATION(continued)
Property Address:
Owner: `5
Date of Inspection: '?
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
---------------
If SAS not Ipcated explain why:
Type
leaching pits.number._
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length: ��i7tR ( 5� f e,A—k
leaching fields.number,dimensions:
UU—
overflow cesspool,number
innovativeialternative system Typeiname of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
g CIA,
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 laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: -
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Page 10 of 11 *
OFFICIAL RgSPEC TION°FORM.l—NOT F_QR YOLUNTAI ASSESSMEmrs
SUBS U ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
P,AIZT,C ,
SYSTEM INFORMATION(continued)
.Property Address: snudoz
a� a
Owner. t
Date of Inspection: — --p
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanentreference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page n of!I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FQR.'VI
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: —f 7
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water__�feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,.date of design plan reviewed:.
Observed site(abutting properryiobservation hole vvAhin I SO geet 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 espblished the high grou d water elev tion: J
e
3 s Ute- �,� Q'� �s �� �► /�J
_Do�S. NGT '\YL-c �j'c) l (_Ikll CVT eik f r)-
PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, INC.
206 ANDOVER STREET, SUITE 11 _
ANDOVER, MA 01810
(978) 475-4370
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address: 114 Spring Hill Road, North Andover, MA 01845
Address of Owner (if different): N/A
Name of Inspector: Peter F. Reilly
(I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 15.000)
Company Name, Address, Phone #: F.P. Reilly & Sons, 206 Andover St., Suite 11
Andover, MA 01810 (978) 475-1237 / (978) 475-4370
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
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
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: September 7, 1998
Peter F. Reilly
The system inspector shall submit a copy of this inspection report to the approving authority 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 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.
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or 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.
: r SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 9/7/98
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
Indicate 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, 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 conforming
septic tank as approved by the Board of Health.
N Sewage backup or breakout or static high water level observed in the distribution box is due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if
(with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system
will pass inspection if (with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A 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 environment.
1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT
THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A The system has a septic tank and soil absorption system and 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 soil absorption and is within a Zone I of a public water supply well.
N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from
a private water supply well, unless a water 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 N/A
(approximation not valid).
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 9/7/98
D. SYSTEM FAILS:
N/A I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should
be contacted to determine what will be necessary to correct the failure.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
N 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 <6" below invert or available volume <%z day flow.
N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
N 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 well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,
attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
N The system is within 400 feet of a surface drinking water supply
N The system is within 200 feet of a tributary to a surface drinking water supply
N The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone II of
a public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater
treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the DEP for further
information.
'i SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 9/7/98
Check if the following have been done:
✓ Pumping information was requested of the owner, occupant and Board of Health.
✓ None of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system recently
or as part of this inspection.
✓ As built plans have been obtained and examined. Note they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage backup.
✓ The system does not receive non-sanitary or industrial waste flow.
✓ The site was inspected for signs of breakout.
✓ All system components, excluding the SAS, 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 facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of SSDS.
The size and location of the SAS on the site has been determined based on:
✓ Existing information (Example: Plan at BOH). DESIGN PLAN / "AS-BUILT" PLAN
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)].
PART C - SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow (gpd/bedroom for SAS): 440 gallons/day (110 gallons/bedroom)
Number of bedrooms: 4
Current residents: 2
Garbage grinder: yes
Laundry connected to system: yes
Seasonal use: no
Water meter readings, if available: est. 150,000 gal. past two years / 205 gpd
Sump Pump (yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of Establishment: N/A
Design Flow: N/A
Grease trap present: N/A
Industrial waste holding tank N/A
Non-sanitary waste discharged the Title 5 system N/A
Water meter readings, if available: N/A
Last date of occupancy: N/A
OTHER:
Describe: N/A
Last date of occupancy: N/A
' SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 9/7/98
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: about two years according to owner
System pumped as part of inspection: no
if yes, volume pumped: N/A gallons
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)
I/A Technology etc. Copy of up to date contract?
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
System installed when dwelling was constructed in 1986.
Sewage odors detected when arriving at the site NO
BUILDING SEWER: (locate on site plan)
Depth below grade: 40"
material 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.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 36"
material of construction: ✓ concrete metal FRP other (explain)
Dimensions: rectangular- 1,500 gallons
<1" sludge depth
32" distance from top of sludge to bottom of outlet tee or baffle
<1" scum thickness
7" distance from top of scum to top of outlet tee or baffle
15" distance from bottom of scum to bottom of outlet tee or baffle
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
Tank was watertight and functioning properly.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 9/7/98
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP 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
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
N/A
TIGHT OR HOLDING TANK: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Capacity: N/A gallons per day
Design Flow: N/A gallons per day
Alarm level: N/A Alarm in working order N/A
Date of previous pumping: N/A
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
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.)
The d-box was level and distributing equally. No sign of solids carryover.
PUMP CHAMBER: N/A (locate on site plan)
N/A Pumps in working order (yes or no)
N/A Alarms in working order (yes or no)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance
or repairs, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 9/7/98
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain: not applicable
Type
leaching pits and number N/A
leaching chambers and number N/A
leaching galleries and number N/A
leaching trenches, number, length three (3) trenches, 50' long each, 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, condition of vegetation, recommendations
for maintenance, repairs, etc.)
Soils over leaching area were good, no evidence 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
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 9/7/98
DEPTH TO GROUNDWATER
Depth to Groundwater >4' (below bottom of SAS)
Indicate all methods used to determine High Groundwater Elevation:
N Obtained from Design Plans on record
Y Observation of Site (abutting property, observation hole, basement sump, etc.)
Y Determined from local conditions
Y Check with Local BOH
N Check FEMA Maps
N Check pumping records
Y Check local excavators, installers
N Use USGS Data
Describe in words how High Groundwater Elevation was established:
Grade sightings from the surrounding area indicate no groundwater in the SAS.
DISCLAIMER
This passing septic inspection under Massachusetts Title V in no way
guarantees the 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 groundwater for 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.
(.�ea
Pet4r F. Reilly
Inspector
September 7, 1998
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 114 Spring Hill Road, North Andover, MA
Owner's Name: Phillip Jacks
Date of Inspection: 7/18/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate where public water system enters house
locate all wells within 100' N/A
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SEPTIC TANK TIES: A to Inlet (1) 20'6" B to Inlet 15'6"
A to Center (C) 18'0" B to Center 17'0"
A to Outlet (0) 20'6" B to Outlet 19'6"
D-BOX TIES: A to Box 55'0" C to Box 70'0"
D to Box 44'3" E to Box :51110*
NOTE: The system is in the rear yard. Point "B" is 34 feet from the right extreme
corner of the house, looking at the rear, at the right side of the sliding
door. The d-box and SAS are well downgrade of the rear of the house
and the tank. Point "D" is the large pine in the rear yard, about
perpendicular with the tank position. Point "E" is at the center of the dual
trunk oak tree about perpendicular with the corner of the house at the
garage. D-box was marked with a wooden stake.
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